Did the UK response to the COVID-19 pandemic fail frail older people?

Rowan H Harwood is a consultant geriatrician and Professor of End-of-Life Care at the University of Nottingham. He is Editor-in-Chief of Age and Ageing.

We must be generous in assessing responses to a crisis. Hindsight is a marvellous tool, and decisions made in good faith in real time may not work out in practice as circumstances evolve. It was right to plan for eventualities such as health services being entirely overwhelmed, and we are fortunate that this never came to pass.

However, we must also analyse and learn lessons so that in future we are even better equipped. I believe that four issues have not worked well for frail older people in the response to the COVID-19 pandemic.

Care homes

Care homes were always vulnerable; residents are frail and live communally. The problems care homes faced were not properly anticipated and effective quarantine of an infected or exposed resident was always going to be difficult. Many care homes responded with early ‘lockdown’, electing to discontinue all visits to protect their residents. However, this was alongside the initial policy emphasis on freeing-up hospital beds by mandating early discharge to care homes, and working on the basis of optimistic infection control assumptions within them. Uncertainty over date of onset and length of infectivity, insufficient testing and relative lack of personal protective equipment in care homes has exacerbated their inherent risk. A precautionary approach would have protected care homes by quarantining new or returning residents for longer. The widespread outbreaks, mortality and threats to residents’ long-term wellbeing suggest we did not get this right.

Demonising acute hospital care

Acute hospital care is neither necessarily futile nor intolerably burdensome. Hospital admissions are driven by crises, acute illness or changes in function or behaviour where assessment and therapy can only be delivered in the hospital setting. We invest a lot of clinical effort in ensuring that people are managed ‘closer to home’ if that is possible, but that is not always possible for a variety of reasons. We know that systematic Comprehensive Geriatric Assessment and Management leads to the best outcomes in terms of survival and function. We also know that sometimes problems at the end of life also need hospital-level care. Most public discussion of hospitals has been around availability of Intensive Care Unit beds, but most patients do not go to ICU, and non-ICU hospital care still has plenty to offer frail older people: monitoring, oxygen, fluids, antibiotics for superadded infections, symptom relief, prevention of complications, optimisation of comorbidities and early rehabilitation. The aggressiveness of the treatment and degree of burden can (and should) be negotiated and agreed. Most ill patients recover and are discharged, and this has not changed. Recently, many with co-morbid conditions have avoided presenting to hospital, or have presented at a later stage of illness, which will have contributed substantially to the excessive overall mortality we have seen in the UK compared with other countries.

Advance care planning

We must all plan for the future, including our healthcare preferences, and this requires a realistic appraisal of treatment benefits. We appear to have come to assume that all frail older people are ready to die, and would not want even measured and relatively non-burdensome efforts to maintain life and encourage recovery of wellbeing and function. A Clinical Frailty Scale Score of 5 or 6 does not imply that death is imminent, even if it means that surviving an ITU admission is unlikely. We have legal and care planning mechanisms to ensure that unwanted medical care is avoided, but also that beneficial options are also considered.  ‘Living well with frailty’ includes avoiding crises where possible, celebrating recovery and coping, and using a shared decision-making process to decide on acceptable care, and remains relevant in a pandemic. Driven by fear of overwhelming hospitals, we have identified people who would not survive an admission to ITU with COVID-19 pneumonitis, and suggested they should all prioritise comfort care, preferably out of hospital. In an overwhelmed health services this may have become reasonable, but in many places this has not happened. We have mixed up measures to target treatment to those who can best benefit with rationing. The ACP ‘brand’ has been damaged, and it will take time for us to reinstate it as a positive aspect of patient care.

‘Herd immunity’

‘Herd immunity’ is a vaccination concept. If a large enough proportion is vaccinated, an infectious disease no longer circulates within the population, and we say that ‘herd immunity’ has been achieved. This protects those who cannot be vaccinated or are otherwise especially vulnerable. Natural infection does not lead to ‘herd immunity’: measles and smallpox were endemic before vaccination. For measles the immune proportion needs to be >90% for herd immunity to occur, and when MMR vaccination rates dropped below this, outbreaks re-emerged. The public health response to an epidemic, as advocated by WHO, is case identification, contact tracing and quarantine. This is what worked for SARS and Ebola. In the absence of a vaccine, a viral epidemic has to be contained and suppressed, yet The UK abandoned this approach far too early and adopted a concept not designed for this application, that risks, rather than protects, the most vulnerable. Prevention was the only way to protect old, frail and vulnerable people.

In summary, whilst there have been aspects to celebrate in our national management of COVID-19, we are also left with questions around how the needs of our frailer population was considered and prioritised, and, how some of the decisions and lost opportunities may adversely impact continuing conversations around illness trajectories and anticipatory planning.


Brilliant ..explains things very well . 

This an excellent and balanced reflection of where we are. Mnay Thanks for this.

Thank-you, a well balanced summary of the UK's response hopefully DoH & PHE will listen and learn for future surges.

Rowan Harwood is one of the wisest people in geriatric medicine and someone who if he is speaking, i will make a beeline to the auditorium or the computer to hear. If I see he has written one of his reflective blogs or articles, i will always seek it out.  I continue to learn from him. I would commend any geriatrician to read both this blog and his site from late April about Covid and older people.

One of many things he said here really resonated with me. We *do* need to stop demonising hospitalisation.  We have now entered a mindset and narrative (well beyond specialist geriatric medicine) whereby hospital is characterised as uniformly bad for older people, inevitably distressing and full of harms with home always being the destination they or their families would naturally want and always better for their outcomes.  Much of this has been driven by our low acute bed base in the UK, rising front door attendance and admission and rising number of back door delayed transfers of care. 

This "hospital bad, home good" narrative, then extends to us as specialists. It is fantastic to see so many intermediate care models including community rehab teams, discharge to assess, rapid crisis response as well as enhanced support to care homes, hospital at home and a greater use of ambulatory care - sometimes off the acute site. And i am delighted to see more geriatricians working in community roles and supporting community MDTs, community hospitals and care homes. 

But when we get into the rhetoric from some folk of "we should all be out of hospital. The specialists and the patients are in the wrong place" this foments completely pointless culture and ideology wars between people in our own discipline often more based on ideology than evidence

As Rowan and others such as Marion McMurdo have argue, we need to make hospitals fit places for older people rather than accepting that they are inevitably distressing and harmful. Moreover we know that plenty of older people and families in crisis *do* seek acute hospital attendance and admission and *do* worry about leaving before they are ready. If we are serious about respecting choice we can't run with "you can have any choice you like so long as it is home. And if you don't want this, you are misguided"> That is the antithesis or person centred care

I would always want more people to be supported at home and don;t want to see any older person trapped in hospital with no acute care needs just waiting for community support. However, geriatricians in the UK are highly trained internal medicine physicians with as much medical registrar experience as any speciality. We have been the main force behind transforming and delivering stroke services, acute front door frailty, improvements in inpatient care for people with dementia, delirium and hip fracture. A large proportion of adults in the acute bed base have frailty, age related multiple long term conditions and yes some of those patients really do need and benefit from acute care. There is often no alternative service and you can only define "inappropriate" bed use with reference to what else is available, Nor have major reviews of alternative care models by the Nuffield Trust and Health Foundation shown that they "save" money.  

Beyond that, the evidence base for ward based speciality led comprehensive geriatric assessment both on general wards (and in effect on Stroke Units and for Hip Fracture Patients) and for other models such as Acute Front Door models is big and growing and in fact greater than the current evidence around community CGA. 

I am absolutely in favour of more focus on prevention care closer to home and older people only being in hospital for so long as it is required. However, there is a central role for excellent inpatient care delivered to the kind of standards set out in the Health Improvement Scotland Guidelines on hospital care for older people. 

But there is more than enough work to go around for geriatricians in secondary, community and primary care settings and in care homes and we could double in number and still have plenty of value to add

So let us, as Rowan says, stop demonising hospitalisation, celebrate the considerable value our speciality has added over the yeras to it, remember the struggles we had earlier in our history to be a mainstream part and mainstay of acute hospital medicine (thereby enhancing our power base and profile and credibility) and let us stop culture wars between acute end and community end geriatricians There is something for everyone in this speciality

And yes, plenty of frail older people do benefit from being in hospital when it is the best, safest or only viable option.

David Oliver






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