Following publication of the number of care home deaths due to coronavirus, much media attention has focused on the government’s response to concerns raised in 2017 in the Exercise Cygnus report(published by the Guardian on 7 May 2020). The report highlighted potential difficulties for the care home sector in a flu pandemic. Stella Perrott considers the findings and their implications for government action.
In 2017, Public Health England disseminated the Exercise Cygnus Report to local and national government, health and prison services. The report was the output of a three-day role-play and testing exercise undertaken in October 2016, devoted to the UK’s capacity to deal with a flu pandemic. The starting point was the guidance and plans derived from a similar exercise in 2011 and over 900 people from a range of organisations and members of the public took part. Exercise Cygnus was preceded by planning for the event, information gathering and an exploration of the key questions to be asked.
The objective was to assess “how well current flu pandemic plans were up to date and robust should there be another pandemic”. Participants considered health care in hospitals, the community, prisons and social care settings, and planned government responses including communication. The exercise was health focused, seeking to identify what needed to be done to manage an outbreak and contain the disease. So, it did not address the way in which lockdown might play a part in suppression or the likely impact on the economy.
The exercise started with a number of best-guess assumptions about the likely rate of contagion, sickness, death and absence from work. Weaknesses were identified across all sectors and plans made to reduce them.
The social care sector was not represented on the exercise other than through senior members of government and local authority departments, or through members of local resilience forums. This absence is noted and the lack of planning and coordination within the sector is raised as a major concern in the report. It is also very evident that lack of participation affected the understanding of the social care sector and the role it might play. It is primarily understood as a resource for assisting health services in managing the volume of patients – a ‘step down’ facility following medical recovery. Therefore, the questions raised about the sector relate to how capacity might be increased.
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Page 21 of the report discusses this in some detail. It notes the disparate nature of social care: that much of it is privately owned and funded, and that no one knows exactly the extent of provision or the degree of separation of residential care from other community and family-based support. Participants were grouped together during the exercise to represent different sectors. Those role-playing the co-ordinating role of the Department for Communities and Local Government were “overwhelmed with information” from those role-playing the social care sector and “the information provided was so inconsistent that they struggled to create from it a coherent picture” from which any national plan might emerge. Meanwhile the care sector group reported that, “the lack of information coming back from ‘the Centre’ would have impeded their ability to act”. These difficulties appear to be playing out in real life four years on.
Had the social care sector been engaged more fully in Exercise Cygnus, and in a way that took into account their role as understood by the sector itself, participants might have questioned the assumed contribution social care could make to patient recovery and freeing hospital beds. Instead of assuming that scaling up residential care places, “would enable adult social care to provide capacity for excess demand in NHS acute care settings”, the report might have made plans for preventing residential care becoming the reservoir of infection, both among workers and residents, that has occurred. In treating residential care as something similar to and supportive of health care – rather than people’s own homes to which other sick people should not be invited – they have misjudged the situation badly and provoked many of the fractious discussions between health and social care of recent weeks. It is evident that health services, which had planned for the transfer of patients to care homes, cannot understand why homes are refusing to accept them and why they will only consider accepting their own residents back once certain conditions have been met.
Lack of involvement from the care sector in shaping the current coronavirus response is matched by the lack of interest shown by government in the sector.
“It is understood that the social care sector is currently under significant pressure during business as usual. There was little attention paid to this sector during [simulated] COBR meetings or the discussions that led in those meetings for decisions to be made. Any extra pressure on the social care sector (especially with a 20-40 per cent absenteeism rate and with illness among vulnerable sections of society) could be very challenging.”Exercise Cygnus Report, 2016
To understand better why the residential care sector poses so many difficulties for emergency flu planning, a comparison with prisons is helpful. In the prison sector, there were high-level strategic plans already in place for dealing with an outbreak; and Exercise Cygnus identified a need for “contingency plans and related procedural guidance”. It reported good inter-agency collaboration and relationships at national level capable of addressing a pandemic, but also recommended that current good practice guidance should be extended to all places of detention. It noted that “Exercise Cygnus did not test the tactical and operational responses to outbreaks in prisons and this should be considered as an area for development”. In other words, and to steal from Donald Rumsfeld, the exercise identified the ‘known unknowns’ in the prison sector, while in the social care sector they had yet to identify ‘the unknown unknowns’. It is as though the government decided to put the problems in the ‘too difficult’ filing cabinet and ignore them while it could.
At some point in the future, the UK’s response to the coronavirus pandemic will be examined more closely. From Exercise Cygnus two points are already evident. The first is that, whatever organisational arrangements a government puts in place for health or welfare services, prisons or education – be those public, private or a mix of the two – it cannot ignore or offload responsibility for the health and wellbeing of those that use those services. The second is that, if a sector that is caring for people for whom the state has a responsibility, then no matter how difficult or complex, the state must engage and ensure that representatives of the sector are involved in planning, policy formulation and information sharing.
Had Exercise Cygnus engaged better with the residential care sector, it might not have made assumptions about the role the sector could play. And had the government acted on the report, the number of deaths in care homes might not have been as high as they are today.