It is difficult to compare mortality rates with infection rates. Each country defines long-term care differently and record-keeping varies. In an article (in Dutch) on the website, Qruxx, Vilans interprets the measures that have been taken in general and the lessons we can learn about how to better handle epidemics or pandemics in the future.
At the request of the Ministry of Health, Welfare and Sport, we at Vilans have followed the corona policies in long-term care of eight similar European countries from April 2020 to June 2021: Belgium (specifically Flanders), Denmark, Germany (specifically North Rhine-Westphalia), France, Norway, the United Kingdom (specifically England), Sweden and, of course, the Netherlands. We monitored websites in the countries and consulted experts and policymakers. We were also in regular contact with international networks, such as the International Long-term Care Policy Network and WHO Europe. This led to quarterly online publications, in which we plotted the measures along a timeline and put forward an analysis. Finally, we held an invitational conference with international experts to share our findings and look ahead towards the near future.
The grass was not greener on the other side
In our own country, we can be quite critical about how things have gone during the corona period. Many things were not in order and a number of mistakes were made. Especially in the beginning of the crisis, we saw that especially nursing homes were hard hit: many residents became seriously ill and many died of COVID-19. The measures taken to control the virus within the facility were extremely spartan: people were denied visits and, demented or not, were cared for by care workers who were completely covered up. And for vulnerable people at home, it was not much better. In fact, many people were under a sort of house arrest.
It was also a difficult period for care workers. In the beginning, there was hardly any protection, many had to deal with horrible deaths and faced confrontations with emotional family members. A large number of staff fell ill, were overburdened and some were even traumatised. Some of them are still struggling with the after-effects of the crisis. On top of that, as the crisis progressed, there was strong criticism not only of government policy but also of the healthcare system. In some instances, this led to threats that required security measures at care facilities.
This may have seemed unique to the Netherlands, but the same thing occurred in the countries we monitored. There were strict visiting regulations or visitation bans, there was a shortage of resources, hospital care took precedence everywhere, and in nursing homes and home care, staff faced very risky situations. In all countries, government policy sometimes changed overnight, a lot of things did not go smoothly and there was also strong criticism of policy. The saying ‘the grass is always greener on the other side’ did not apply this time. The grass was very dry and badly damaged everywhere.
During the second wave, the ‘British’ variety emerged. The picture was very different from the first wave. All the countries monitored were much better prepared, with sufficient protective equipment and testing facilities. Furthermore, nowhere were all institutions closed or visits prohibited. The uncertainty about the new variants however, caused much reluctance to relax measures.
We saw more customisation. In the case of local or regional outbreaks, measures were increasingly taken per region, per municipality or even locally per institution. The individual institutions were given more freedom to implement policy according to the specific situation. In all countries there were debates whether the measures in the first wave had been humane and whether the harsh measures of the first wave had been in the best interest of the clients. People’s welfare became more and more an element in the debate. The ethical debate was in full swing, although it was often not labelled as such. Nevertheless, people remained very wary of the danger of infections. The conclusion was: we will never do this again: making quality of life secondary to survival.
Aftermath and preparation
At present, all countries are seeing high vaccination coverage among long-term care clients and a sharp decline in mortality rates. Although infections and deaths are increasing again, the situation is not nearly as dramatic as it was a year ago. The vast majority of the employees have been vaccinated, but a large number have not. We see that in the other countries as well. And there are now sufficient resources.
But still we cannot say that we have managed well. There is still a lot of corona-related suffering (among others Long COVID), a lot of absenteeism (also due to infections in society), people are walking around with traumas, are tired and emotional. Resilience seems to have run out. And this has been going on for a while. In the countries monitored, we also see that this has taken a heavy toll on staff and that their resilience seems to have run out. And everywhere it is difficult to find enough well-qualified personnel. Governments, employers and employees are trying to find collective solutions to this. There is a discussion about salaries, for example. Work in long-term care is underpaid in all countries, with the Netherlands being the least affected. Compensation for the adverse effects on health and corona-related suffering is also still a subject of discussion.
And for the future, the vaccination requirement for healthcare workers in all countries is a difficult discussion, including privacy issues and penalties for unvaccinated workers. Unlike previous non-corona related vaccinations, this discussion is more heated and emotional. Employers are afraid to reject unvaccinated staff because it would lead to a disastrous shortage of workers. But clients and especially family members often demand that only vaccinated workers are employed.
Dare to decentralise
So far, there are many similarities between the Netherlands and other countries. But there were also differences that lead to five lessons for the future. First of all, during the corona period (and still today) we saw that the pace at which countries acted differed, as well as the degree of austerity. With the exception of Sweden, the Scandinavian countries were fast and strict with their measures. There was a high level of compliance in the population. In the Nordic countries, citizens had more confidence in their governments than in the southern countries (and the Netherlands).
The Scandinavian decentralised administrative model worked out quite well. There, the municipalities have almost full responsibility for long-term care, including COVID-19. The number of COVID-19-related deaths was low, again with the exception of Sweden. Municipalities quickly took measures to isolate, test and vaccinate infected clients and institutions. Faster than the Netherlands. In Norway, the central government intervened at a certain point because the measures taken by some municipalities were too strict.
Lesson 1: decentralising responsibilities can work quickly and well. Centralisation does not necessarily lead to better results.
Simplify the responsibility for vaccination logistics
Vaccination logistics, purchasing and registration were challenges everywhere, with many issues surrounding waiting times and vaccination planning for vulnerable older people. In several countries, staff at care homes were vaccinated at the facility itself, at the same time as the residents (e.g. Belgium and Germany). This was usually done by general practitioners. In Denmark, Norway and Sweden, the regions and local authorities also had great autonomy over the vaccination policy. As a result, there were considerable regional differences in who was vaccinated and where.
In the UK, both healthcare professionals and qualified volunteers performed vaccinations under supervision. And that occurred in many different settings. The speed of vaccination also varied greatly between countries. The British were fastest for the total population (partly carried out by supervised volunteers). Pragmatism was often the starting point.
The Danes were fastest in nursing homes and with vulnerable people at home. Germany, Belgium, France and the Netherlands were slower. The Netherlands was an exception. Responsibility for vaccinating vulnerable people lies with various parties, depending on the care facility and the funding. One client was vaccinated by the general practitioner, another by the geriatric specialist, and a neighbour living on her own – by the Municipal Health Service. A lot of confusion, misunderstanding and frustration because the responsibilities in medical care are assigned differently in the various legislation.
Lesson 2: simplify the responsibility for complex vaccination logistics, keep budgeting and accommodation arrangements out of the equation and allow room for pragmatic solutions. Arrange locally who does what.
Society can best protect long-term care
Although by June many vulnerable people had been vaccinated in all countries, in our last monitoring exercise we saw that there were still many restrictions in place to prevent infection. In general, visits from clients in institutions were limited to ‘bubbles’ with restrictions on social interaction (in Belgium, for example, one hug-contact). But the pandemic made it clear that despite all measures, the virus still affects the vulnerable. A comparison of mortality figures showed that the degree of infection in the community was more or less the same as that in nursing homes.
In other words, the more people in society are infected, the more people in nursing homes are affected. More or less the same measures have been taken in long-term care in all countries. Without these measures, there would undoubtedly have been many more victims. But the mortality figures also show that the main cause of infections in nursing homes comes from society.
Lesson 3: You cannot isolate nursing homes from society. The most effective entry point for infection control for a virus like SARS-COV-2 is outside the nursing homes.
Smarter stockpiling and strengthening of reserves
More than ever, we have learned the value of resources. Testing, for instance, has proven to be important. But that requires a lot of inventory. The same applies to vaccines or protective equipment. Whereas the aim before the pandemic was to have a ‘lean’ healthcare system, it is now very important to have some meat on the bones: reserves of materials, people and money.
The dilemma is that this increases costs, the demand for personnel and waste. In all countries, possibilities for the temporary scaling up of care personnel have been explored. In Germany and Belgium, for instance, the army was deployed for support functions, and in the Netherlands also to provide care. In several countries, former employees (re-entry workers) with a professional background were also recruited. In France, people with an employment disadvantage and paid volunteers were recruited to perform auxiliary tasks. In other countries (as in the Netherlands, to a limited extent), people without a professional care background were enlisted (catering, aviation, events), in Flanders also Red Cross volunteers. This raises the question of whether we actually need the qualifications that are currently required for all activities.
Lesson 4: establish resources for vital functions and identify the professional qualities that are absolutely necessary. Be innovative in our professional structure. A crisis scenario can help to prepare us for a future with more scarcity and with changing reserves. In this regard, we actually missed opportunities last year.
It was clear in all countries that corona measures posed an ethical challenge. Denying visitation rights was one of the most drastic and dramatic measures, prioritising the protection of residents from the virus over emotional and physical contact with loved ones. The ethical consideration may well be different next time, particularly as the situation is different. But now organisations and healthcare professionals must find their own way of balancing ethical considerations.
As for discussions concerning advance care that are frequently held in Dutch nursing homes and among older people living independently, we have heard little about them in other countries. There, too, ethical considerations play a role in a number of cases. And in fact, this also applies to decisions about where to deploy people and resources.
Sweden was quick to formulate an ethical framework for difficult discussions at all levels; from the patient level to the national level. The pandemic brought and continues to bring with it many ethical issues that are only marginally discussed in an open and structured manner.
Lesson 5: be prepared for the ethical issues of a pandemic, but also for providing quality care in an ethical manner in times of scarcity.
By looking abroad you learn a lot about your own country. We cannot always take our assumptions for granted. In the same way, the pandemic has challenged our assumptions. But what have we learnt about the resilience of our system of long-term care, and perhaps of the entire healthcare system? We believe that resilience requires room to manoeuvre, nationally, but certainly also locally. Temporary relaxation of national rules and trusting that there is local expertise and responsibility to implement the right measures are part of this. This requires resources that are able to ‘breathe’. It also involves making ethical choices. This applies not only in times of crisis and scarcity but also in times of peace and wealth.
Finally, healthcare is not external to society. Healthcare is part of society and vice versa, and resilience in society affects resilience in healthcare. The reverse is also true in times of pandemics, and even in an extreme way. We must make good use of the time ahead to strengthen the resilience of the healthcare system. No matter how tired everyone is, we have to do it. Because the corona crisis has taught us that if we don’t work on resilience now, we’ll be behind the curve again in the next crisis. How about tackling these five lessons first?