Mary Daly, Marga León, Birgit Pfau-Effinger, Costanzo Ranci and Tine Rostgaard examine COVID-19 and residential care for older people during the first wave of the pandemic in Denmark, England, Germany, Italy and Spain. Their analysis shows a clear cross-national clustering: Denmark and Germany group together by virtue of the proactive approach adopted, whereas England, Italy, and Spain had major weaknesses resulting in delayed and generally inadequate responses. They show that this clustering is embedded in particular long-term care policy systems that predated the pandemic.
COVID-19 has been a sharp exogenous shock for health, economic, and social policies across the world. Despite the transnational nature of this crisis, policy responses developed mostly within the boundaries of nation states. Governments declared their ‘states of emergency’ to provide an immediate response to an unprecedented health crisis. With political action focused strongly on strengthening the capacity of hospitals, in some countries this was at the expense of underestimating the vulnerability of other institutions. Nursing homes seemed to be a particular blind spot and the death toll has been high, although there is significant cross-country variation in nursing and care home mortality. It is important to explore this variation and ask why it emerged.
These questions are the focus of or recently published article which interrogates developments relating to care homes and the pandemic by placing them within the long-term care (LTC) system. Policy responses to the COVID-19 crisis in nursing homes during the first wave of the pandemic (roughly March to June 2020) are analysed in five countries: Denmark, England, Germany, Italy, and Spain. The empirical focus is on political decisions regarding lockdown, virus testing and the supply of personal protective equipment (PPE) in care homes vis-à-vis hospitals. The analysis revealed both variation but also cross-national patterning reflecting LTC policy regimes. In sum, the evidence makes clear that the variations in these policy responses are associated with the features of national care policies and the national LTC system.
The governments of Denmark and Germany started early in the pandemic to offer precautions and protection for older people in care homes by restricting access and supporting isolation in care homes, whereas these measures came very late and were often weaker in England, Italy, and Spain. We found a particularly severe form of neglect of the protection of older people in care homes in England and Italy. In these countries, care homes were sometimes used to discharge COVID-19 patients from hospitals, with the risk that they infected other care recipients.
With regard to testing, it is clear that governments in the five countries often did not support testing in care homes in a comprehensive and efficient way. However, here again there is a difference in that in Denmark and Germany, care homes were more prioritised for testing purposes than in England, Italy, and Spain. With regard to PPE, only the German government promoted its use in care homes and hospitals on the basis of guidelines and policy interventions from the start of the pandemic on. The Danish government offered such an integrated strategy towards PPE as well, but started it somewhat later. In England, Italy, and Spain, governments substantially under resourced care homes with regard to PPE.
Taken as a whole, countries followed two broadly different policy approaches. Policies in Germany and Denmark placed care homes on a more or less equal footing with hospitals from early in the pandemic. In contrast, decision-makers in England, Italy, and Spain viewed COVID-19 mostly as a hospital emergency and offered protection with regard to access, testing, and PPE mainly for hospitals. This latter approach was based on a substantial neglect of the protection of care recipients in care homes.
Are there specific institutional features of each national LTC system that might be associated with this variation in policy responses? For the inter-locking factors, we looked at three elements of ‘policy capacity’ – resourcing, level of regulation and co-ordination of governance and provision. According to our findings, the LTC systems in place in Denmark and Germany are characterised by a relatively high degree of political support regarding economic and human capital resources, regulation of care homes, and institutional coordination of the LTC system. It seems that these were favourable conditions for emergency policies enabling the prioritisation of care homes in their responses to the pandemic and offering important resources for care homes that could be used to protect care recipients. In England, Italy, and Spain, where the resourcing of and political support for care homes and LTC more broadly is weaker, care homes were downgraded in comparison with hospitals. As a result, policy interventions and emergency measures were introduced with substantial delay, and media investigations and public outcry played a major role in forcing governments into action.
Broadly speaking, our view is that national policy legacies and structures explain the diverging capacity of the different systems to confront the pandemic in two main ways. First, they affected the capacity to provide care homes with the necessary protective measures to face the risks of the virus; secondly, they shaped the ability to provide effective regulation and coordination mechanisms to navigate through the emergency.
It seems that lessons were learnt from the first phase of the pandemic with care homes generally better protected and experiencing lower mortality rates in subsequent periods. The cross-national patterning regarding responses and associated outcomes has also changed somewhat. But it is open to question whether LTC systems and the degree of priority given to social care have changed significantly. The bottom line is that weaknesses in existing provision – especially in terms of resourcing or the priority given to social care policy – magnified and continue to magnify the pandemic’s negative outcomes.
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Note: the above draws on the authors’ published work in Journal of European Social Policy.
Mary Daly is Professor of Sociology and Social Policy in the Department of Social Policy and Intervention, and a Fellow of Green Templeton College at the University of Oxford.
Marga León is Professor of Political Science at the Universitat Autònoma de Barcelona.
Birgit Pfau-Effinger is Research Professor for Sociology of Cultural Change and Institutional Change (Senior Research Professor) at the University of Hamburg.
Costanzo Ranci is Professor in Economic Sociology at the Politecnico of Milano, where he chairs the Social Policy Lab.
Tine Rostgaard is Professor at Stockholm University and Professor MSO at Roskilde University.
Photo by Isaac Quesada on Unsplash.
