Covid-19 and the Sector of the Long-Term Nursing Homes

Abstract

Chapter 6, entitled “Covid-19 and the Sector of the Long-Term Nursing Homes” of the book titled “Covid-19 and Capitalism - Success and Failure of the Legal Methods for Dealing with a Pandemic”, has as a first objective to examine, on the one hand, what the outlook of the sector of the nursing homes for the elderly was after decades of sustained neoliberal privatization policies, and to what extent this highly privatized sector was still able to cope with the outbreak of a pandemic. The second part of this chapter aims at examining how this sector, and with it the vulnerable population group of the elderly, withstood the Covid-19 pandemic itself. Methodologically, it has again been deemed necessary to rely heavily on research evidence and factual research provided by an amalgam of policy institutions, academic researchers, and specialized investigative journalists. The importance of this factual research cannot be overemphasized, as it shows how years of sustained privatization policies had eroded the sector, leaving it unable to respond adequately to a pandemic. This chapter therefore meticulously synthesizes the findings of these institutions and authors, in each case with explicit acknowledgment that the institutions and authors cited have, in many cases, been the original authors of the relevant, thus quoted positions and opinions. This chapter paints a rather bleak picture of the impact of neoliberal reorganization and privatization on a sector that is nevertheless vital to global public health in general and to the well-being of the vulnerable population group of the elderly. It thereby appears that neoliberal policies have paved the way for a veritable blood sheet, because of which, throughout the Western world, thousands of elderly people have died prematurely, in many cases without any prospect of adequate medical care or, in some cases, even basic human treatment. This at the same time implies a plea to bring this sector back into public hands, an issue that is itself related to the issue of public funding of countries and their governments. Referring to previous research, the author again concludes by raising the question whether the development of new models of public financing, based on an allocation model rather than on the levying of taxes and on public debt, has not become even more pressing as a result of the Covid-19 pandemic.

6.1 The Long-Term Nursing Home Sector Before Covid-19

6.1.1 Europe

6.1.1.1 European Privatization Climate as of the 1990s

It is perhaps an understatement to hold that the Covid-19 crisis rekindled the debate about the efficiency and quality of the—strongly privatized—long-term nursing home sector.

The privatization of state-owned enterprises, or other types of public institutions, hinges on orthodox, neoliberal hypothesis that private ownership brings greater efficiency and more rapid economic growth.¹ In addition, privatization—purportedly—increases output and lowers costs, while adding to reduce public internal and external debt (= the so-called “austerity” argument, within the EU also relevant in applying the so-called “ESA2010-standards”), and to promote individual initiative by rewarding entrepreneurship. By implementing this policy, states express their belief that they will improve overall economic performance and growth, and increase rational choice for consumers, thus contributing to a more performant socioeconomic order. Although usually rationalized in the name of greater efficiency, privatization has as main, true effect that it concentrates wealth even more in the hands of a few and makes the public pay more for what it needs. While privatization has been very crucial in deploying neoliberal, public policy, it is increasingly becoming a debated issue whether it indeed improves the economy or actually makes it worse.²

The main argument deployed for the privatization of healthcare and long-term nursing homes, is the one that has been used for rationalising privatization in general. Privatisation is supposed to lead to more economic efficiency, to enhance the quality of products and services, to generate less waste, and to improve customers’ and patients’ choices. These purported positive effects of privatization are attributed to the fact that, when operating on the free markets, economic actors are assumed to allocate scarce resources (more) rationally and in a more optimal manner than can be accomplished in a public environment.³

According to Mercille, privatization of nursing homes in Europe became a significant policy approach after the election of the Thatcher government in the United Kingdom, and has proceeded apace ever since.⁴ As of the 1990s, neoliberal governments all over the EU started conducting rounds of privatization of nursing homes to meet deficit reduction objectives imposed by the EU (under the rules of the Maastricht Treaty of 1992; cf. Sect. 5.2.1.2.1).⁵ As concerns the latter factor, in general, euro area countries are constrained by rules of European law that prohibit member states’ budgets from exceeding 3% of their Gross Domestic Product (GDP) and that dictate that they must keep their budgets balanced over the medium term. During the past decades, severe cutbacks in the healthcare and long-term nursing sector have been one of the methods to achieve this goal, thus also further feeding the privatization debate (cf. already Sect. 5.1.).

The pressure that the EU has put on several of its member states to push for a privatization and marketizing of various sectors of socioeconomic life, notably the healthcare and long-term nursing sectors, can hardly be underestimated. The arguments that have been used to justify this privatization and/or marketization of the healthcare sector (esp. hospitals) have already been set out in Chap. 5. These same arguments have also been deployed to achieve the privatization and/or marketization of the long-term nursing home sector, both sectors often being dealt with as one regulatory category.

A possible difference between the two sectors has been that the privatization of long-term nursing institutions has gone much further than that of the hospital sector, probably because hospitals need to rely more on highly qualified medical staff than long-term nursing homes, which made it easier for the latter category to be subjected to free market organization.

As such, the EU does not have direct competence to regulate both these sectors. However, the EU has in an indirect manner used its monetary and fiscal competence to steer its member states towards a higher degree of privatization and marketization. (Cf. Sect. 5.2.1.1) This especially applied to EU member states that experienced financial problems—e.g., in the aftermath of the financial crisis of 2008—which made them more vulnerable to far-reaching EU austerity measures, as European monetary or financial support from either the ECB or the Stability Pact was often made dependent on conditions of liberalizing (e.g., through privatization or similar techniques) the healthcare and/or long-term nursing sector.

Among many other examples, reference can again be made to the (extreme) example of Italy. It has already been pointed out in Chap. 5. (cf. Sect. 5.2.1.2.2) how, when Italy became dependent on European monetary and fiscal support in 2011, the country also came under severe pressure from the European institutions to implement far-reaching reforms, including privatizations. This was already discussed in the letter from the ECB leadership to the Italian government of 5 August 2011 quoted in Chap. 5., which pointed out the need for liberalization of various public services. These policy instructions would later become even more clear in the “2019 Joint Report on Healthcare and Long-Term Care Systems and Fiscal Sustainability”, in which the following conclusion on the necessity for severe austerity measures were reached about the long-term nursing sector:⁶

Italy has a system of long-term care that focuses on cash benefits as much as on residential and home care. Based on the current features, the main challenges of the system appear to be:

• Improving the governance framework: to establish a coherent and integrated legal and governance framework for a clear delineation of responsibilities of state authorities concerning the provision of long-term care services; to strategically integrate medical and social services via such a legal framework; to define a comprehensive approach covering both policies for informal (family and friends) carers, and policies on the formal provision of LTC services and its financing; to establish good information platforms for LTC users and providers; to deal with cost-shifting incentives across health and care.

• Improving financing arrangements: to determine the extent of user cost-sharing on long term care benefits; to extend means- testing to cash benefit provisions, to include assets in the means-test used to determine individual cost-sharing (or entitlement to public support) for B&L costs better reflects the distribution of economic welfare among individuals.

• Providing adequate levels of care to those in need of care: to adapt and improve long term care coverage schemes, setting a homogenous need-level triggering entitlement to coverage; the depth of coverage, that is, setting the extent of user cost-sharing on long term care benefits; to provide targeted benefits to those with highest LTC needs.

• Supporting family carers: to establish policies for supporting informal carers, such as through flexible working conditions, respite care, carer’s allowances replacing lost wages or covering expenses incurred due to caring, cash benefits paid to the care recipients, while ensuring that incentives for employment of carers are not diminished and women are not encouraged to withdraw from the labour market for caring reasons.

• Ensuring coordination and continuity of care: to establish better co-ordination of care pathways and along the care continuum, such as through a single point of access to information, the allocation of care co-ordination responsibilities to providers or to care managers, via dedicated governance structures for care co-ordination and the integration of health and care to facilitate care co-ordination.

• To facilitate appropriate utilisation across health and long-term care: to arrange for adequate supply of services and support outside hospitals, changing payment systems and financial incentives to discourage acute care use for long term care; to create better rules, improving (and securing) safe care pathways and information delivered to chronically-ill people or circulated through the system; to steer long term care users towards appropriate settings.

• Improving value for money: to invest in ICT as an important source of information, care management and coordination; to invest in assistive devices, which for example, facilitate self-care, patient centeredness, and co- ordination between health and care services.

• Prevention: to promote healthy ageing and preventing physical and mental deterioration of people with chronic care; to employ prevention and health-promotion policies and identify risk groups and detect morbidity patterns earlier.

• Improving administrative efficiency.

6.1.1.2 Methods Deployed for Privatizing Public (Health) Institutions in General

On a legal-technical level, privatization has been qualified as a rather “loose concept”. A possible definition could be that reference is made to the direct sale to a private party, or the private market listing, of the entire, or a substantial part, of a state enterprise or public institution. According to neoliberal theory, such state enterprises, or other public institutions providing services, ought to be dismantled and turned over to the private sector, because of their assumed constraining effects on the freedom of individuals to conduct business, while other strands of neoliberal theory argue that market mechanisms, amongst which free competition, offer more guarantees for ensuring correct pricing and economic efficiency. Whatever the approach, neoliberalism urges for such public enterprises or institutions to be turned over to free market players.⁷

According to Mercille, “privatization” is in any case a “multi-layered” process that may be accomplished through several channels and by resorting to a wide variety of legal instruments, including:⁸

• 1. Ownership (e.g., when public assets, such as nursing home ownership and/or ownership of shares of companies running nursing homes, are transferred to private persons).

• 2. Financing (e.g., when sources of financing public assets and/or services become private thus replacing public funding).

• 3. Management (when, e.g., based upon government concessions or similar legal instruments, private entities start managing and operating public assets).

• 4. Production (e.g., when private enterprises start delivering a good or service, often after outsourcing by the public sector).

According to Eurofound, the division and definition of public and private services of healthcare institutions (in the broad sense of the word) can be made according to criteria such as legal status, ownership and economic activity. For private service providers, an important factor is whether their services have been contracted out by the public sector or are part of public policy in some other way, as the conditions in which services are provided is similar to public provision.⁹

As data on the number of subsidized places in private nursing homes are limited, this makes the distinction between public and private status of nursing home mainly defined and differentiated by type of ownership, legal status, and/or economic activity. The definitions of public and private used by Eurofound, are, moreover, similar to those of the European Commission’s study on social services of general interest (SSGI).¹⁰ Hence, the notion “public providers” refers to organizations in which public authorities (e.g., Ministries, municipalities) either directly manage or have the power to appoint management, while “private service providers” are defined as providers which are not public authorities, or other bodies governed by public law.¹¹ Private providers of service can be either “for-profit” or “non-profit”. Non-profit, private providers are defined in the Commission’s SSGI study as institutions or organizations created for the purpose of producing goods and/or providing services but whose status does not permit them to become a source of income, profit or other financial profit for the units that establish, control or finance said institutions or organisations.¹² In practice, this can include organizations the board of directors of which is composed by volunteers, as well as organizations that are managed or owned by religious or civil societal entities (e.g., trade unions, political parties, cooperatives, churches…).¹³ Private for-profit providers include organizations that are controlled by shareholders, or that are in another manner privately owned.¹⁴

Mainstream explanations for the privatization of nursing homes claim that private nursing homes are more economically efficient than their public counterparts. This is to a large extent rebutted by critical scholars who have demonstrated that the evidence on this matter is far from conclusive and even, as has been made clear during the Covid-19 pandemic (cf. Sect. 6.2), points to the opposite.¹⁵ Financial performance may in some cases improve after a privatization, but through implementing severe austerity measures, staff working conditions (including wages, working time, vacation rights…), consumer protection, and quality of service all drastically deteriorate.¹⁶

The “new public management” (NPM) discourse that advocates for increased private provision on the grounds that competition between service providers will increase the quality and efficiency of services at a reduced cost to the public sector, puts the emphasis on performance, contractualization and the adoption of management practices from the private sector. In this approach, market mechanisms and quasi-markets are to be introduced, so that different types of providers would compete with one another. These reforms and market mechanisms include tendering, commissioning, user choice, user fees, and vouchers.¹⁷

As of the 1990s, the private sector has determined the outlook of European public healthcare and long-term nursing institutions in multiple ways: through outright privatization in cases where public facilities, such as hospitals or nursing homes, were simply sold off to private investors; through outsourcing of certain services and handing them over to private enterprises, such as cleaning and catering, or even through the creation of internal markets between service providing facilities and buyers of health services.¹⁸

Mercille has, furthermore, pointed out that, in recent years, increasing use has been made of PPP structures for the furnishing of nursing homes.¹⁹ The notion PPP, an abbreviation for “public-private-partnership”, typically refers to an operation whereby a state (or other public entity) and a private contractor enter into a long-term contractual agreement (usually ranging between 20 and 30 years) for the building, maintenance and/or exploitation of an infrastructure project, such as a hospital, a nursing home, a road, a school building … The public partner hereby gradually repays the private contractor (for his commitment of building, maintaining and/or exploiting the facility) over a number of years. In most cases, the private partner has a substantial degree of freedom over matters like project design and inputs. PPP-projects have also been referred to as a form of “spread-in-time” privatization on a contractual basis, to the extent that they imply a form of withdrawal from the part of the state (or another public entity) from a given economic activity and/or public service provision, while the private partner gradually increases its involvement.²⁰ According to Navarro-Espigares and Hernandez-Torres, public-private partnerships in the health care sector have taken various forms, with different levels of involvement and responsibility from the side of the private partner, and different levels of risk allocation to the respective public and private partners. PPP-projects in the nursing home sector are, furthermore, usually characterised by the sharing of common, agreed upon objectives.²¹

Another technique concerns the so-called “Private Finance Initiatives” (abbreviated as “PFI”) that usually involve a concession agreement. These have been used as a distinct means of financing large capital investments, based upon funding provided by private partners. The technique has especially been used in the United Kingdom, where private consortia often enter into long-term agreements with the government in order to finance, build and, less often, manage new projects in the health and nursing home sectors. This method commonly consists of a private consortium financing the construction of a health facility, that is then leased to the public partner(s).²²

In Europe, PPPs have been resorted to in an increasing extent since they were first developed in the United Kingdom in the early 1990s. According to Mercille, between 1990 and 2015, more than 1800 PPP agreements have been concluded in the EU, for a combined value of more than EUR 350 billion.²³

6.1.1.3 General Public Policy Supporting the Privatization of Nursing Homes

The privatisation and commercialisation of health and long-term nursing care, as well as the pursuit of public-private partnerships in the health care sector and the cuts in public spending, all encouraged under EU economic governance, has put many European countries in an extremely bad position for responding to the Covid-19 pandemic.²⁴

In recent times, neoliberal governments in several European countries not only welcomed private initiatives for establishing nursing homes, but moreover actively encouraged private investors to take up business in the nursing home sector through various fiscal, financial and corporate legal measures. A major corporate law-policy supporting the spread of for-profit private nursing homes has been a scheme of “capital allowances” for expenditure on the construction or refurbishment of private nursing homes (but also hospitals). Such incentives, e.g., encouraged the construction and upgrading of private healthcare facilities by giving tax breaks to investors. In some cases, governments also provided generous subsidies to private investors for building projects in the private healthcare sector.²⁵

Regarding the public initiative itself, fiscal policies initiated by the EU in recent decades (e.g., through the so-called ESA 2010-standards) generally held public investments in a dim view, especially when it concerned infrastructure works.²⁶ As a result, EU member states were in many cases obliged to call upon the private markets if they still wanted to meet certain needs, e.g., building or furnishing nursing homes.

Furthermore, faced with the EU’s highly restrictive budget and austerity measures (cf. Sect. 5.2.1.2), EU Member States themselves were in many cases no longer able and/or willing to keep up with rising demand in the public care home sector, often preferring to pay private home operators to make up this shortfall, another phenomenon adding to the factors behind the rapid development of private nursing homes from the 1990s onwards.²⁷

As a result of this combination of public policy incentives, the increased demand for nursing homes has in a vast number of European countries often been met by the private sector. All of this, of course, goes back to neoliberal theories which hold that it is cheaper for states to outsource public services to private operators, than to provide them themselves, especially in cases where this implies investments in the construction and/or maintenance of (new) facilities.

This strategy may be qualified as typically “neoliberal” to the extent that it fully “privatizes” the profits to be made by conducting certain “marketized” activities, while at the same time “socialising” the costs involved. These “socialised costs” may range from financial contributions that have to be paid for the outsourcing of projects, to further human costs, amongst which: (1) the fact that the burden of poorer quality care has to be borne by society, most notably by the patients and their families, and (2) the fact that nursing home staff members employed in the private sector usually suffers under poorer employment conditions, such as lower salaries, in addition to numerous other less attractive working conditions (e.g., extended working hours, less vacation benefits, less sick leave benefits…).²⁸ Public homes, moreover, usually have more (qualified) nursing staff than private homes, which implies that more nurses and other (qualified) personnel have to be paid. In addition, staff costs (both for nurses and other care staff) are usually higher in the public sector, because public nursing homes have to comply with the better working conditions imposed by public sector employment legislation (e.g., paid sick leave and maternity leave) and because they have to supply the more expensive, unprofitable care not given by private facilities. Similarly, public nursing homes often have to continue to serve geographical areas for which it is not profitable enough for the private sector to establish care facilities (e.g., remote rural areas). This is an important factor in why the costs for society increase due to privatization, as the private sector is only interested in acquiring the profitable market segments, leaving the unprofitable ones in the hands of public entities. Private homes also often outsource certain aspects of their operation (such as cleaning and catering). This is beneficial for shareholders but detrimental for the patients/consumers, to the extent that this often leads to lower quality service.²⁹

These findings are largely confirmed by Eurofound’s 2017 study already quoted above, from which it appears that financial pressure on nursing homes has been a major issue (e.g., in the United Kingdom), initiated by the rising number of people in need of elderly care, and the increasing costs of expanding staff and services to guarantee quality care. According to this study, private investors clearly deploy strategies of (1) location and (2) selection towards potential service users. E.g., as nursing homes in rural areas imply bigger costs and/or smaller profits, private investors abstained from locating there. The same applied to the users of services private nursing homes were willing to accept as clients/patients. The types of residents prevalent in each type of nursing home were, hence, influenced by the profitability of the services they required—residents who require less profitable care services were more likely to end up in public nursing homes.³⁰

The private sector is in addition highly “under-regulated”, leaving employers with relatively few social constraints. It has even been assessed that under current regulation, those who reduce the workforce to a level they can get away with, are mostly rewarded, ultimately leading to a reduction in the quality of care (a typical race to the bottom- the effect of lowering regulatory requirements). This truth, moreover, not only applies to the working conditions of the staff, but also to (the lack of) rules and regulations applying to conducting a nursing home in general. As a result, the proliferation of new private facilities in recent decades has raised concerns about quality, as some new operators have no background or expertise in the sector, while they are allowed to operate largely unregulated and unmonitored.³¹

In the United Kingdom, where private equity investors of for-profit nursing home operators have been said to have “skimped on operating budgets” in order to maximise private investors’ returns, the “Institute for Public Policy Research” has found that private nursing home operators provide less training, pay staff less and employ less staff. These factors add up to a higher staff turnover and to lower quality of care, but also, when the provider goes bankrupt (often due to too much debt), local authorities still have to take on financial responsibility. In the opinion of the Corporate Europe Observatory, this is the classic effect of privatization in the mid-term run: profits have disappeared in private pockets, but when things invariably go wrong, the costs have to be borne by the taxpayer.³²

6.1.1.4 Some Figures

6.1.1.4.1 Public Versus Private Nursing Homes

The ongoing privatisation of the nursing home sector throughout the EU must be situated within the above context. Per the dictates of economic neoliberalism, in many countries, private ownership has grown in importance during the last decades.³³

In the United Kingdom, e.g., 78% of nursing home beds were in private for-profit facilities in 2016, with the public sector reportedly struggling.³⁴ As for Ireland, 2017 data similarly showed that nursing homes had been privatised at an increasing rate over the past few decades (cf. Fig. 6.1). According to Mercille, in the 1980s, public nursing homes still accounted for about 60% of the total number of nursing home beds at a national level, with private for-profit organisations owning about 25% of the number of beds and private non-profit organisations the remaining 15%. Since then, the situation has drastically changed. Data from 2017 showed that public nursing homes only accounted for 22.2% of the total number of nursing home beds, while private for-profit nursing homes provided 68.8% and private non-profit nursing homes provided 9.0%.³⁵

Fig. 6.1

Percentage of total beds by nursing home ownership in Ireland in 2017 [Source: Mercille (2017), p. 4 (further explaining how she collected this data)]

According to the already quoted study of Eurofound, by 2011, long-term nursing homes were almost exclusively privately provided in the Netherlands, Germany, and the United Kingdom (England and Scotland). Around that time, in the Netherlands the law stipulated that nursing home services were to be provided entirely by the non-profit sector. In Germany too, non-profit provision was predominant, although there were significant regional variations. On the other hand, in the United Kingdom (England and Scotland), private provision of nursing home beds was mainly for-profit. Private provision of nursing home beds constituted 20% or less of the total in the Nordic countries, some eastern European countries (namely Estonia, the Czech Republic, Romania and Slovenia) and finally Greece, where the institutionalised provision of long-term care was very limited. Said study of Eurofound also highlighted the lack of cross-sectional data and, moreover, indicated that the data available showed a shift towards the private provision of long-term nursing services, driven by an increase in relying on vouchers and cash benefits.³⁶

Table 6.1 gives an overview of the share of nursing homes provision in Europe in 2017.

Table 6.1 Share of nursing homes provision in Europe^a

The study of Eurofound also quoted from another source of data for the year 2012, which had pointed out that the private provision of long-term nursing services was particularly high in the Netherlands (where it was almost entirely non-profit) and in Germany and the United Kingdom (where it was mainly for-profit). This alternative source of data quoted by Eurofound also confirmed that most long-term nursing services in the Nordic countries and in eastern Europe were still provided by the public sector.³⁷

The data of this alternative source are presented in Fig. 6.2.³⁸

Fig. 6.2

Distribution of providers of nursing homes according to ownership (%)

From the data gathered and quoted by Eurofound, it, furthermore, appeared that less than one-quarter of the total number of long-term nursing homes in Greece, Germany, the United Kingdom (Scotland), Ireland and Italy were still in public hands. In the case of Greece, there were even only two public nursing homes for elderly in the entire country. By contrast, the public provision of long-term nursing services constituted more than half of the total in the Nordic countries and in central and eastern Europe (with the exception of Croatia, Lithuania and Romania).³⁹

Taking into consideration the changes in the total number and the “market” share of nursing homes over—roughly speaking—the period from 2004 until 2016, the data gathered and referred to by Eurofound demonstrated that the number of public nursing homes had increased considerably in Slovakia (by 39% between 2004 and 2017) and in Romania (by 30% between 2008 and 2014). In both countries, this was at the same time coupled with a much higher growth in the number of homes in the private sector,⁴⁰ pointing to the fact that in those countries there was probably a catch-up going on, whereby before elderly people had been more cared for at home or in a family setting rather than being admitted to nursing homes. This took place in Romania, where the number of private nursing homes substantially increased from 42 in 2008, to 141 in 2014. Similarly, Slovakia’s 116 private nursing homes in 2004 had ballooned to 267 in 2017. Moreover, in some of these countries, the share of private provision increased: private nursing homes in Romania constituted around one-third of the total in 2008, whereas in 2014 they represented more than half of all nursing homes.⁴¹ The Romanian example points to a public policy stimulating the private provision of healthcare services in general. The astounding 236% growth of the Romanian private care home sector is in part attributable to the reform of Romania’s health system in 2009, when health insurance was discontinued for 66 public hospitals due to high operating costs and the low numbers of patients. These hospitals were all closed in April 2011, although some later reopened as ordinary nursing or residential nursing homes for elderly. Of these, 19 were still operational in 2015, with a total of 966 beds and 896 enrolled beneficiaries.⁴² Aside from national policy, European policies regarding structural and investment funds also played an important role in the development of private nursing home facilities in Eastern Europe. E.g., from 2007 onward, several funding opportunities became available to NGOs to “rehabilitate, modernise, develop and equip social service infrastructure”; the eligibility of these NGO private projects had, moreover, been restricted to the north-east and Bucharest-Ilfov regions.⁴³

The number of both public and private nursing homes also grew (albeit to a lesser extent) in Lithuania, Malta, and Spain. In Lithuania, pointing to a similar evolution whereby elderly care was increasingly institutionalized. In these countries, at the beginning of the 1990s, the management of public nursing homes was moreover transferred from the state to local authorities. By 1994, care institutions owned by the state had still accounted for less than 20% of the total number of public nursing homes, with the rest being managed by local authorities. On the other hand, in Malta, while the number of non-profit nursing homes owned by the church decreased slightly as of 2009, the numbers of both private and public homes for elderly were on the increase. By 2016 there was an equal number (15) of church, private and public nursing homes. The rate of growth of the nursing home sector in Spain was very similar to that of Malta. Yet, during the first decade of the twenty-first century, the public nursing homes sector was still increasing more than the private nursing home sector, with the number of public nursing homes reported of increasing by around 25%, with a smaller increase in private nursing homes. Until 2011, the nursing homes sector as a whole increased at a rate of around 6% per annum. However, public budget cuts and decreasing purchasing power resulting from the economic crisis limited this increases to just 0.2% between 2010 and 2011, with subsequent decreases afterwards. The crisis particularly hit private centres with “arranged” places (that is, with places in private nursing facilities subsidized with public money).⁴⁴

According to the study of Eurofound, Cyprus was the only country (for which data were available) where there had been an increase in public nursing homes and a decrease in private ones. While public provision increased by around 10%, around one-third of private nursing homes closed, partly due to a reduction in state funding to non-profit providers.⁴⁵

A large group of countries saw a clear decrease in public nursing homes, while the number of private nursing homes was clearly growing: This was, e.g., the case for the Czech Republic, Croatia, Germany and Slovenia.⁴⁶

In Croatia, the number of public “social welfare” nursing homes (mostly established by local and regional authorities) for both older and infirm persons had decreased from 46 in 2003, to 45 in 2014. All new nursing homes in Croatia established between 2003 and 2013 were of a private (mainly for-profit) nature, with the market share of private nursing homes having increased significantly from 15% in 2003, to 27% in 2013. The main driver behind this increase was the lack of capacity in state and other public homes to meet the increased demand for accommodation.⁴⁷

In Germany, the introduction of long-term care insurance in 1994 was followed by reforms inspired by the ideas of “new public management”, such as opening the market to private providers in order to increase competition, introducing contract-based management between the state and the service providers, and the allocation of public funds by healthcare insurers who also negotiated agreements with service providers. This policy approach led to an increase in private, for-profit providers within the care sector, and the general restructuring of institutionalised forms of nursing provision—especially in the case of private, non-profit providers. The number of public nursing homes in Germany decreased by 14%, from a total of 649 in 2003, to 555 in 2013. During this period, the number of private, non-profit providers increased by 29%, and that of private, for-profit providers by 49%. As a result, the total share of nursing homes that were of a private (both for-profit and non-profit) nature grew to 95% of the total.⁴⁸

In Slovenia, the private sector started to provide institutionalized nursing care in 1999, in order to meet the increasing demand for such services that could no longer be met by the public sector. Between 2007 and 2015, the number of public nursing homes decreased from 74 to 59, while the number of private nursing homes increased from 14 to 39.⁴⁹

There was also a last group of countries, where both public and private institutionalised nursing provision declined. This group of countries included France, the United Kingdom (notably Scotland) and Norway (in the latter country with the exception of private, non-profit nursing homes, which grew from 33 to 40 between 2009 and 2015).⁵⁰

In Norway, private non-profit nursing homes (which in the past had mostly been linked to religious institutions) had in most cases become integrated in the municipal healthcare system, with the services these homes provided differing little from those in municipally run nursing homes themselves. Up until 2006, private non-profit providers had struggled when competing with private for-profit providers. This was attributed to the fact that they had to ensure the same level of benefit pensions as public providers, while at the same time facing higher costs.⁵¹

For the United Kingdom (notably England), the Institute for Public Policy Research (IPPR), as quoted and referred to by Eurofound, indicated the evolution of the nursing homes sector as “the story of how deregulation in the financial sector, sometimes referred to as financialization, has transformed not only (the) economy but also (…) public services.”⁵² Notably, since the 1970s, when the majority of healthcare was still provided by the state, provision in England inexorably shifted towards the private sector, moreover dominated by for-profit providers. From data gathered by Future Care Capital and (again) referred to by Eurofound, it appeared that this process has been ongoing since then.⁵³

By comparison, in Scotland, between 2004 and 2015, the biggest decreases were in the private, non-profit sector and the public nursing homes sector, with nearly one-quarter and one-fifth respectively of nursing homes closing.⁵⁴

According to another study from the IPPR,⁵⁵ by September 2019, more than eight out of 10 nursing home beds (namely 84%) in the United Kingdom were provided by private, profit-driven companies, in most cases owned by small, local entrepreneurs,⁵⁶ but also more than 50,000 nursing home beds were provided by large operators owned by private equity firms.⁵⁷ In the past, these had considered the care sector as an easy way to get rich fast, although their business model had in many cases started to falter, esp. because of the financial crisis of 2008.⁵⁸ According to Blakeley and Quilter-Pinner, these large private equity-backed providers engaged in long-term nursing, at the same time got increasingly involved in the real estate markets through the ownership of vast amounts of land. Experts estimated that, as of the 1980s, over £30 billion of capital costs had in this manner been invested in the nursing sector. This was especially typical for the “residential care” -model. However, because of this, such providers increasingly got involved in the nursing services market, not because of their specialism in providing nursing services, but because of the advantages of a debt-based real estate boom.⁵⁹

Table 6.2 gives an overview of the market share and ownership model of the largest care providers (brands) by beds in the United Kingdom in 2019.

Table 6.2 Market share and ownership model of the largest care providers (brands) by beds in 2019^a

As a result of this evolution, local councils in the United Kingdom had almost completely withdrawn from this important segment of social care that they heretofore dominated.⁶⁰ According to Campbell, private for-profit enterprises owned 381,524 (83.6%) of the 456,545 nursing home beds in England.⁶¹

However, the fact that private equity-backed enterprises had taken over a significant proportion of long-term nursing provision in the United Kingdom was no longer seen as so positive, as these private, for-profit enterprises were increasingly fuelled by debt⁶² and driven by the prospect of rising property prices and ever-decreasing nursing costs, which was believed to put the socially vital long-term nursing sector at increasing risk.⁶³

In contrast, 13% of long-term nursing beds were still provided by the voluntary, non-profit sector and 3% by so-called local councils, which had previously been the main provider of long-term nursing care for vulnerable older people for decades.⁶⁴ However, since 2015, 91% of local councils in the United Kingdom had increased their use of private long-term nursing home beds as an alternative for directly providing these services themselves. Based on analysed trends in nursing bed use by 147 of England’s 151 local councils, 133 had resorted to this outsourcing method; by contrast, only 14 had reduced their reliance on privately nursing homes.⁶⁵

Private enterprises thus increased their market position regarding long-term nursing homes in just a few years, while the government itself had repeatedly cut basic public social care funding for local councils. Although the total government spending had increased during recent years, the £21.3 billion that was granted to local councils in 2018 amounted to £700 million less than the £22 billion that had been put into social care in 2010–2011.⁶⁶ The IPPR was said to urge the UK’s ministers to make the state a major provider of nursing homes again by spending £7.5 billion to provide up to 75,000 additional beds by 2030, with a focus on long-term nursing provision provided by local councils or private non-profit organisations. IPPR expected this to be necessary to help cope with an expected sharp increase in the number of people over-75 and over-85 during the decade to follow.⁶⁷

In France, over a 15-year period, financial incentives had been granted to private for-profit enterprises, as well as home care agencies, to enable them to enter the long-term nursing market. Between 2007 and 2011, the share of public and private nursing homes remained stable and unchanged (48% and 52% respectively).⁶⁸

6.1.1.4.2 Available Beds in Nursing Homes

While the aforementioned Eurofound-study provides access to plenty of data on the amount of nursing homes broken down by ownership, similar data on the relative share of available spaces in these homes was a bit scarcer. During the periods mentioned in the Eurofound study, the share of available places seemed similar to the share of nursing homes in most countries, with the exception of Malta, Romania, Slovakia and Slovenia, where the share of places in public nursing homes was significantly higher than the actual market share of the public nursing homes themselves (by more than 10 percentage points). According to Eurofound, this suggests that in this latter group of countries, public long-term nursing homes were larger in size than their private counterparts. In all these countries, the number of places in both public and private nursing homes had increased over the decade in question, with the largest increase occurring in the number of beds in private nursing homes. Most countries for which data was available saw an increase in the number of beds available in both the public and private sectors over the investigated period. This was the case in Belgium, Spain, Malta, Romania and Slovenia. As with nursing homes, the largest relative increase in the number of places in private nursing homes occurred in Romania (from 1538 in 2008 to 5601 in 2014, an increase of 264%). This increased the proportion of places in private nursing homes from 20% to 44%.⁶⁹

The number of places in public nursing homes had increased more rapidly in Malta (by 65% between 2009 and 2016). Despite a decrease in the number of church-owned homes, the total number of beds available in Malta had increased in all categories of nursing homes since 1992.⁷⁰

Between 1996 and 2016, the total number of beds in Belgium in the residential nursing home sector had increased by 35%. The largest increase had been in Flanders, where the market share of private beds had increased by more than 20% between 2003 and 2013. In contrast, the total number of nursing beds in the Brussels region had decreased since 2001, due to an overcapacity of beds (especially in private nursing homes). The only type of beds that increased slightly (by 2%) between 2003 and 2013, were in non-profit nursing homes. In the Walloon Region, the number of beds in non-profit institutions had also increased (by 17%), while the rest had remained more or less stable.⁷¹

In Spain, reports from the National Institute for Elderly and Social Services (IMSERSO), as again quoted by Eurofound, distinguished between “public places”, “private beds based upon public subsidies” (“concertadas”) and (fully) “private places”. The data for 2010 showed that of the total number of long-term nursing beds available (368,805), 25% had been offered in public facilities, 27% had been publicly subsidised places in private nursing homes, and 48% had been purely private places. The percentage of subsidised places in private centers, compared to the total number of available places, increased from 15% in 2002 to 27% in 2010.⁷²

Another group of countries, referred to in the report of Eurofound, consisted of those where the supply of private beds had increased and the supply of public beds had decreased; this was the case in Austria, France, Ireland, Lithuania, Slovakia and, to some extent, Norway, where the number of private for-profit beds had decreased.⁷³

In Austria, with the introduction of the so-called “long-term care allowance” (or, in German “Pflegegeld”) in 1993, the total number of nursing beds had increased significantly, while the number of beds in public and private non-profit nursing facilities had stagnated from 1998 onwards, and the share of private for-profit beds (and profit-making nursing homes themselves) had continued to increase - so much so that in 2010 they accounted for about one fifth of all nursing beds.⁷⁴

In Ireland, the market segment of private providers for nursing home care for the elderly had increased significantly between 2003 and 2014, with the number of private beds having increased by 49%, and the number of public nursing beds having decreased from around 9000 to 6656. This evolution was believed to have been facilitated by tax breaks for the construction of private nursing homes, which had been in force from 1997 to 2009. The aim of these tax breaks had been to increase the overall supply of nursing home beds in order to relieve the pressure on public hospital beds, which were used to care for the elderly in areas with relatively few nursing home beds. Although there was no explicit policy to replace public nursing beds with private ones, the existence of the tax breaks for the private beds, along with the lack of investment in public nursing beds, effectively supported this trend. The increase in the total number of beds was thus mainly due to the expansion of nursing beds provided by the private sector. In 1988, there had almost been 15,000 long-stay nursing beds, almost half of which had been provided by the public sector (such as health council geriatric hospitals and nursing homes). In 2015, the total number of nursing places had almost been 30,000, but with only 23% provided by public nursing homes.⁷⁵

In Norway, the number of privately operated beds in care homes remained relatively stable, although it increased slightly between 2012 and 2015 due to an increase in the number of beds offered by non-profit providers. However, this stability masked a significant shift from non-profit providers to commercial providers. The number of beds in non-profit nursing homes had evolved little from the 1980s, but eventually declined after 2010. Between 2000 and 2011, 30 nursing homes run by private, non-profit providers were reported to have closed. Municipalities also had the opportunity to enter into long-term contracts with non-profit providers, without having to go through a tendering process. Since the government, NGOs and employer organisations had signed a cooperation agreement in 2012, the number of beds offered by non-profit facilities has stabilised. The growth of commercially run nursing and care homes has since been slower than expected; this was largely due to the fact that the use of public tenders in this area was limited to a small number of municipalities.⁷⁶

From the early 1990s, an increasing amount of nursing beds in UK nursing facilities were provided by the private sector, with the for-profit private sector accounting for the lion’s share of said places. The increase in provision in the independent (for-profit) sector was driven by a government policy that called for a “mixed care provision” and the application of the “best value” principle, which—as has already been explained before (cf. Sect. 6.1.1.4.1)—in practice led to more outsourcing of local public goods to the private sector, as this was assumed to bring greater cost savings compared to the care provided by local councils. This policy not only reflected in the numbers of private vs. public homes, but also in the division of places. As a result of these reforms, in 2014 in the United Kingdom as a whole, there were 187,800 places (86% of total capacity) in for-profit nursing homes, 17,600 in not-for-profit nursing homes, and 12,300 National Health Service (NHS) long stay beds. In total, the 25 largest private, for-profit facilities provided 30% of the nursing home beds (with 15% provided by the four largest, private organisations alone: “Four Seasons”, “Bupa Nursing homes”, “HC-One Ltd.” and “Barchester Healthcare”), and the remaining organisations each providing 0.4% or less of the total capacity. In Scotland, over the decade in question, there was a decrease of around 20% in the number of public and not-for-profit beds, while the share in beds of the for-profit sector increased by just under 10%. Given these changes, in addition to the fact that the private for-profit sector was likely to operate larger homes, the proportion of for-profit beds in 2015 was 79% of the total, compared with 73% in 2004.⁷⁷

Figure 6.3 gives an overview of the changes in the share of private beds in the period 2002–2016 in some European countries.

Fig. 6.3

Changes in the share of private beds in the period 2002–2016 (%). [Source: Eurofound (2017), p. 19]

6.1.1.4.3 Size of the Nursing Homes

In the opinion of Eurofound, combining the data on the number of nursing homes and the number of beds gives an idea of the differences in size between public and private nursing homes. In the periods surveyed by Eurofound, public nursing homes in Slovenia and Malta had on average more than twice as many beds as private ones. In Norway, private nursing homes were approximately 50% larger than public ones, while private nursing homes also had a larger capacity in Sweden. On average, all types of nursing homes were smaller in the United Kingdom (notably in Scotland) and in the Czech Republic. The average number of registered places per nursing home in the United Kingdom (Scotland) was 42 by March 2014. Nursing homes were also small in England: in 2010, local authorities operated on average larger residential nursing homes (24 beds) and “common” nursing homes (54 beds) than the private for-profit sector (19 beds and 48 beds respectively) or the voluntary sector (15 beds and 36 beds respectively). In Germany, most public or non-profit nursing homes had between 60 and 150 places, while 50% of private for-profit homes had between 10 and 50 places.⁷⁸

In terms of changes over time in the average size of nursing homes, most countries for which data were available (Lithuania, Spain, Malta and Romania) saw a decrease in the average number of places in public nursing homes and an increase in the size of private nursing homes. This was the case in the United Kingdom (Scotland), where the average number of places per nursing home increased (38 in 2004) as older homes probably made way for larger purpose-built facilities. Also in Ireland, the number of private nursing home beds increased significantly in the period between 2003 and 2014, from 14,946 beds to 22,343 (an increase of 49%), although the number of homes increased only slightly, from 408 to 437 (by 7%). According to Eurofound, this shows that most new beds had been added by placing additional capacity in existing homes. Some 42% of participants in a survey conducted in Ireland in 2014 planned to expand capacity by an average of 19 beds over the next year. In France, nursing homes have increased their capacity by 5% since 2007. At the end of 2011, the average capacity was 68 (or 719,810 places for 10,481 facilities). In Denmark, there was also a trend towards building larger homes with more residents. However, the opposite trend was seen in Lithuania, where there was a decrease from 202 beds in 1990 to 48 beds in 2015.⁷⁹

6.1.1.4.4 Number of Staff

In relation to the relevant period(s) covered by Eurofound’s study, the size and number of nursing homes also largely related to differences in staffing levels. In Scotland, where most beds and nursing homes were private, 87% of nursing home staff, in 2014, worked in the private sector (the majority in the for-profit sector), compared with 13% employed by nursing homes run by local authorities or the NHS. In England, this percentage was even smaller. In total, there were around 555,000 jobs in nursing homes in 2015, representing 42% of adult social care jobs, or 38% when only nursing homes are considered. Only 4% of the residential care related jobs (26,500) were provided by facilities run by local authorities, and their number had fallen by around 30% between 2011 and 2015. This was mainly due to organisational restructuring, outsourcing and closure provision.⁸⁰

Staff members in residential care were one of the jobs for which demand increased the most in Europe between 2011 and 2015—by 16.2%. Changes over time in employment rates reflected changes in the number of nursing homes and beds.⁸¹

The Eurofound study included some other figures relating to some European countries:⁸²

• (1) Germany: The number of staff in public nursing homes decreased by 11% between 2003 and 2013, while the number of staff members in private non-profit institutions increased by 26% and in private for-profit institutions by 67%.

• (2) Slovakia: Between 2005 and 2013, the number of employees in nursing homes increased by 39%, while the share of employees in non-public providers rose from 10% to 18% of the workforce working in nursing homes.

• (3) Latvia: Nursing homes employed 217 workers in 2014. Of these, 29 (or 13%) were employed in private institutions.

• (4) Romania: The number of staff in private nursing homes increased from 99 in 2008 to 406 in 2013. The effects of the financial crisis from 2008 onwards led to a moratorium on recruitment in public institutions. Although the average size of public nursing homes was larger than that of private homes, public nursing homes had only in large cities (such as Arad, Brasov, Bacău and Iaşi) more than 50 employees.

• (5) Finland: The number of staff members in privately managed institutions for protected living increased from 8353 in 2012 to 11,054 in 2013. This was presumably partly related to the introduction of the “Elderly Facilities Act” in 2012, in addition to a recommendation of a minimum staff-to-resident ratio of 0.5:1. There was also a notable increase in the number of staff members in privately managed homes from 2009 to 2010, and an even steeper decrease from 2012 to 2013, for which the explanation was not clear.

• (6) Croatia: The average number of employees in public social homes for the elderly and sick was 64 in 2003 and 79 in 2014, while the average number of employees in private homes was 17 in 2003 and 22 in 2014.

6.1.1.4.5 Number of Service Users

The largest increase in the number and proportion of residents in private nursing homes over the periods covered by the above-mentioned Eurofound study was observed in Romania, reflecting the increase in private care provision in said country. In Romania, the share of residents in private nursing homes rose from 21% of the total in 2008, to 44% in 2014. The number of users also increased in Finland, Croatia and Poland, both in public and private nursing homes.⁸³ In all these countries, the increase in the number of nursing home residents was greater in the case of private than in the case of public nursing homes. Between 2004 and 2014, Croatia recorded the largest increase in the number of residents in public nursing homes of all countries for which data were available (35%), as well as a significant growth in the number of residents in private nursing homes (119%). In Germany, Hungary, Lithuania, Sweden and Slovakia, the number of residents in public nursing homes decreased, while the number of residents in private nursing homes increased. The number of residents of nursing homes in Lithuania more than doubled between 1990 and 2015. At the end of 2015, there was about 5% of beds free in all types of nursing homes for the elderly in Lithuania.⁸⁴

The decrease in the number of residents in Swedish nursing homes was explained by an increase in the number of people receiving care at home. However, home care only partly compensated for the reduction in the number of residents admitted to nursing homes. The decreasing coverage could, more precisely, also be partially explained by the improved health of the elderly, but overall it had simply become increasingly difficult for elderly people in need of help to get a place in a nursing home (something that was often brought up in policy debates). The increase in the number of residents in private nursing homes could be due in part to the 2009 Law on System of Choice in the Public Sector (the LOV Act), which allowed long-term care users to choose a service provider. As of June 2016, about 158 of Sweden’s 290 municipalities had introduced a LOV system in some form; 15 of these had introduced it in an area of special housing for the elderly.⁸⁵

In Cyprus, Greece and the United Kingdom, the number of care home users had decreased. Although no data are available for Greece before 2014, the president of the Greek Nursing Home Association noted that since the start of the financial crisis in 2008, a wave of departures from nursing homes had been registered, especially among non-dependent care users. Before the crisis, these nursing homes were at full capacity with waiting lists.⁸⁶ This suggested that elderly people without need for special care went back to living with their children in order to help their families.

Previous research by Eurofound had similarly shown that, as a result of the 2008 financial crisis, older people in Latvia, Hungary and Portugal moved out of care homes and into their children’s homes to support the household financially with their pensions. The number of local authority funded nursing home residents in the United Kingdom (England), in a similar manner, fell to around 213,000 in 2014, representing a 22% decrease between 2004 and 2014. The percentage of local authority funded places provided by the for-profit sector had steadily increased from 88% in 2004 to 96% in 2014. Overall, 50% of nursing home residents received local authority funding. In Scotland, the number of long-stay residents in public and not-for-profit nursing homes decreased between 2005 and 2015, while the number of long-stay residents in for-profit nursing homes increased slightly (3%) over that period.⁸⁷

6.1.2 The United States

6.1.2.1 The Changing Structure of the Nursing Home Industry in the 1980s

The first and probably most intensive wave of submitting the American socio-economic system to neoliberal doctrine, had already been accomplished in the 1980s under Ronald Reagan’s presidency. Hence, it should come as no surprise that the reorganization of the long-term nursing home sector was largely accomplished during that period as well, roughly a decade before the countries of the EU started to follow the same path. As a result, from the 1980s onwards, the stay in an American nursing home became to an increasing extent a commodity service that was offered on the free market, rather than a public service.

The efforts of the Reagan administration to “neoliberalize” the US socioeconomic order of the 1980s in general led to an increasing “corporatization” of American healthcare, by some even considered as the most important development in this sector since the enactment of Medicare and Medicaid.⁸⁸ (On the latter, cf. Sect. 5.2.2) In the opinion of Hawes and Phillips, through this, the for-profit segment of the modern healthcare sector gradually gained prominence, characterised by a rapid growth of proprietary “corporate chains”.⁸⁹

Even before Reagan, the US nursing home sector had already been dominated by in-house private providers as early as the late 1960s, with the sector becoming increasingly dominated by publicly held corporations over the decades.⁹⁰ By the 1980s, nursing home care had become big business and was even said to be the third largest segment of the American healthcare sector. At the time, the sector was, moreover, expected to continue to grow due to an increasing life expectancy of the American population, shifts in morbidity and changing socioeconomic patterns regarding family life. The anticipated need for additional long-term care beds at the time was hereby believed to present policymakers with an important opportunity to influence the future of the long-term care system. While for-profit facilities already owned more than 75 per cent of the US nursing homes, they were still expanding rapidly in the nursing home and life care markets. Moreover, the cost of nursing homes was rising at an even faster rate than the cost of hospital care. Discrimination against unprofitable Medicaid recipients—i.e., those with more severe and expensive care needs—was widely acknowledged in this process.⁹¹

By the 1980s, the nursing home industry could generally be considered as an outgrowth of Medicare, albeit with much older and more complex roots. More precisely, the nursing home sector was believed to have formed out of the following factors: (1) a fusion of government funds (through various social security/Medicare programmes), (2) a growing need due to both socioeconomic and demographic changes and shifts in disease patterns regarding chronic illnesses, and (3) the interaction of policies directed at other types of care facilities (e.g., poorhouses, psychiatric facilities and acute care hospitals). During the process of growth of the long-term nursing home sector, the industry had also been altered in diverse manners. Some of the most profound changes included an increasingly medical-oriented environment, a shift from smaller to larger institutions, and a shift from government-owned and/or volunteer homes to third-party owned private homes. The sector had, as said, also witnessed an increasing concentration of ownership in multi-facility corporate chains that diversified both vertically and horizontally.⁹² Especially during the 1970s and 1980s, the long-term nursing home sector had thus become characterised by an increasing concentration and corporatisation of ownership. This transformation was, moreover, enhanced by numerous regulatory impulses, such as changes in public reimbursement (under Medicare and Medicaid programmes), as well as regulatory policies in matters such as health planning and restrictions on bed supply, besides easier access for “corporate chains” to expansion capital and tax incentives.⁹³

As a result, the quality of care and quality of life for the residents of the private nursing homes became increasingly problematic, with a widening gap between the excellent care and opulent luxury offered to the upper crust of pensioners, and the seriously substandard care pushed on everyone else. According to Hawes and Phillips, in many ways, the aforementioned changes in the American long-term nursing home sector but mirrored the developments in the American health care system in general. Throughout the American healthcare system, there was thus an increasing tendency towards “corporatisation”. In this way, the emergence of the large, multisystem corporate healthcare providers, as stimulated under neoliberal public policy, heralded a new era for American healthcare.⁹⁴

6.1.2.2 Present-Day Outlook of the Nursing Home Sector

By 2019, the US long-term nursing home market was estimated at USD 443.2 billion. The demand for what was referred to as “long-term care” (abbreviated as “LTC”) had increased even more due to the recognition of unmet needs of the elderly that could no longer be met in traditional hospital settings. The US Department of Health and Human Services (HHS) at the time estimated that approximately 69% of the American population would require long-term care for an average of about 3 years during their lifetime, which stimulated demand.⁹⁵ In 2019, both long-term nursing homes and the provision of home care to elderly people continued to be the main segments of the American healthcare market. However, at the same time, long-term nursing homes and hospitals were no longer the only options for healthcare for the elderly. Rising healthcare spending in said facilities had turned the provision of nursing care at home into the de facto preferred option for many elderly people in need of special assistance. With an increasing preference and demand for home care, healthcare service providers started to introduce modern technologies and software to expand on the variety and quality of home care.⁹⁶

In 2017, more than two-thirds of the nursing beds in the United States were privately owned for profit, and more than half were owned by corporate chains.⁹⁷

At the time of the Covid-19 outbreak, 70% of nursing homes were profitable institutions.⁹⁸

6.2 Impact of Covid-19

6.2.1 Europe: When the Free Market Becomes a Killing Machine—Part 2

6.2.1.1 Why European Nursing Homes Were Unprepared for Covid-19

6.2.1.1.1 The General Landscape of Nursing Homes by 2020

Considering the foregoing, it should not come as a surprise that the highly privatized long-term nursing home sector was hardly prepared when Covid-19 struck the European continent, especially given its problem with a shortage of staff in general, and a shortage of qualified staff more specifically.

In essence, at the moment Covid-19 reached the European continent, there were still two main types of long-term nursing homes for the elderly operating in the various EU countries:

• (1) On the one hand, there still existed “public nursing homes” organized by public authorities. These “public nursing homes” had become increasingly subjected to stringent financial reporting obligations, indirectly enforcing austerity.

• (2) On the other hand, there was the growing sector of private institutions for elderly care, some for-profit, others non-profit.

The operation of the private for-profit nursing homes was based on the principles that govern all private companies, in particular the principle of profit maximization and cost minimalization to the ultimate benefit of the shareholders.⁹⁹

In essence, the operation of such nursing homes organized under the legal form of a private (capital) company does not differ from other private companies: Profit is maximized, on the one hand, by realizing as much turnover as possible (in other words, by selling one’s own product or service as much and as expensive as possible) and, on the other hand, by driving down costs as low as possible. To achieve the latter objective, a wide variety of methods may be applied such as: keeping the number of staff low; keeping wages as low as possible (cf. the “Iron Law of the Wages”); looking for the cheapest suppliers (e.g., of material, of food, etc.); outsourcing sub-tasks; postponement of investments; saving on non-immediately profitable expenditure (such as prevention material) …

The limit to such cost-savings is however twofold: On the one hand, the maintenance of a sufficient degree of attractiveness of the services offered on the market, especially in comparison to what competitors have to offer; on the other hand, external quality requirements, such as government regulation that imposes minimum quality demands. However, the neoliberal sticking point lay especially on the last point. The neoliberal EU has, more precisely, enacted an impressive amount of regulation establishing minimum quality and protection rules in certain “critical sectors of the economy” (e.g., banking, finance, and insurance), but this is in sharp contrast with the scant regulatory interest for the care sector in general, and for the sector of long-term homes for the elderly in particular. Accordingly, the interest of national governments of the EU member states themselves in taking strong regulatory action against the nursing home sector is also low. As a result, the private long-term nursing homes sector are, to a large extent, allowed to function entirely in accordance with the basic principles of capitalism,¹⁰⁰ especially regarding its most crucial working aspects, such as staffing, and therefore also the care service provided.

6.2.1.1.2 Issues with Quality

According to Mercille, research generally shows that private for-profit health systems are generally less efficient, more expensive and less egalitarian, and that they lead to the provision of lower quality of care. According to this author, systematic reviews of homes for the elderly have especially pointed to the fact that private for-profit long-term nursing homes for the elderly provide a lower quality of care,¹⁰¹ in other words, that they do not fulfil the criterion for their existence. One of the reasons why for-profit homes tend to provide a lower quality of care is that they have to face higher expenses for activities unrelated to care. A prime obstacle are the shareholders. They typically expect a 10–15% return on investment which has to be earned out of the general turnover of the nursing facility and can thus not be spend on guaranteeing quality service. Other elements which may lead to increased costs without resulting in better quality care concern the fact that taxes may be higher than in the non-profit sector or the public sector, and that executives of private, for-profit companies are likely to obtain higher salaries and bonuses than their colleagues in the non-profit or public sector. As a result, for-profit organisations have stronger incentives to cut costs on matters that relate to the care they provide, thus minimising care expenses, ultimately leading to lower quality.¹⁰²

Studies from the 1970s already described how private nursing home operators, at the time mostly still feeding on public money, cut corners to increase their profits, e.g., by providing low-quality food to residents and/or by employing fewer and cheaper, often less-qualified staff.¹⁰³

By contrast, the 2017 Eurofound report, which based its review on a large number of available studies between 2000 and 2017, made no decisive findings on differences in service quality between public and private nursing homes; however, results still varied from country to country.¹⁰⁴ (Cf. Sect. 6.1.1.4.1).

A study by the IPPR of September 2019 regarding the private nursing home sector in the United Kingdom (cf. already at Sect. 6.1.1.4.1) did find evidence that increasing reliance on private facilities led to lower quality of care. The IPPR saw the following indications with possible links between ownership and quality:¹⁰⁵

• Firstly, there was evidence that private providers had less staff training, higher staff turnover and lower wages.

• Secondly, the market for private healthcare had proven to be volatile, with companies owned by private equity investors, expecting a sufficient return on investment, and operating under highly leveraged business models.

• Third, the rise of large private providers contrasted with evidence that small nursing homes provide better care.

The same IPPR survey found that there was a correlation between the size of a provider and the quality of the facility. 89 per cent of both small nursing and residential nursing homes in the United Kingdom were according to the study rated as good or excellent by the CQC in 2017, compared to only 65% and 72% of the large nursing and residential homes respectively. This was of particular importance given that analysis by the CQC had at the same time indicated that larger long-term nursing homes—including those owned by private equity-backed providers—accounted for an increasing share of the nursing homes market in the United Kingdom.¹⁰⁶

According to Eurofound, having a manageable staff-to-service user ratio, generally, increases the potential personal attention given to service users; it also avoids having a high turnover of staff due to excessive workload. According to its study, the latter has, e.g., occurred in France, where excessive workload had become the main reason why nurses and assistant nurses left their job. Nursing facilities facing labour shortages of (qualified) staff are also likely to face higher staff turnover rates. A qualitative study of 2016 (with 51 interviews and participatory observation) conducted by the “Upper Austrian branch of the Chamber of Labour” and quoted in the Eurofound-study itself, found that low staff-to-resident ratios worsened the working conditions of staff in both nursing and residential nursing homes. This was also the case in several other provinces in which the Chamber of Labour conducted similar studies (Vienna, Lower Austria, Styria and Tyrol).¹⁰⁷

One of the main criticisms regarding the private sector is that because nursing services are, by definition, labour intensive, as “nursing” or “care” has to be provided by one human being to another, profit on such nursing or care services can, basically, only be enhanced by reducing wages and staff. Evidence gathered by Eurofound’s “Network of European Correspondents” and referred to in the Eurofound-study, indeed showed that the number of employees per resident was in general lower in the private sector in several of the countries analysed in said study.¹⁰⁸ In the United Kingdom in particular, the above-quoted study of the IPPR from September 2019 raised huge concerns over the staff-to-residents ratio in the nursing homes owned by big corporations. There was strong evidence that private providers had lower levels of staffing, higher staff turnover, lower rates of pay and lower levels of training. Numerous studies, including one by the Care Quality Commission, highlighted the link between the quantity and quality of the workforce, and the quality of the nursing and care provision itself.¹⁰⁹

Hence, one of the major problems that healthcare facilities across Europe faced at the outbreak of the Covid-19 pandemic has been a lack of (qualified) staff, not only in long-term nursing homes, but even in general hospitals. For a combination of reasons - including austerity in the public sector, and the sector of private institutions operating on the principle of “the maximization of profits and minimalization of costs” that generally determines the functioning of capitalist enterprises—nursing and care facilities across Europe especially faced a shortage of qualified nurses and care givers. This phenomenon was all the more characteristic for nursing and care homes operating in the countries most affected by EU austerity in the aftermath of the financial crisis of 2008 (although the phenomenon also occurred in US private nursing and care homes).¹¹⁰

There was, moreover, a problem with low wages paid by both public and private providers. In 2016, the wages of personal care workers employed in residential care were ranked in the second-lowest quantile (medium to low paid), while the wages of personal care workers in home care ranked in the lowest quintile.¹¹¹ In Germany in particular, in 2014, wages in private nursing homes were, on average, lower than in non-profit and public nursing homes. Due to the high number of low-wage helpers in the care sector, in 2009, the Minister of Labour even extended a collective minimum wage agreement on care assistants (“Pflegehilfskräfte”) concluded by the “United Services Union Ver di” and the non-profit organization “Arbeiterwohlfahrt” (AWO). Covering the care assistants/helpers in all residential nursing homes, in 2016 the agreement provided an hourly wage of EUR 9.75 in western Germany and EUR 9 in eastern Germany; the statutory minimum wage was EUR 8.50.¹¹²

From the study of the IPPR of September 2019, it similarly appeared that there was a downward trend on wages of the staff of the UK nursing homes, esp. regarding the for-profit nursing homes which were owned by large private equity-backed providers (cf. Sect. 6.1.1.4.1). According to Blakeley and Quilter-Pinner, the close relationships between financial interests and social care providing in these long-term nursing homes had drastically reshaped corporate governance throughout the sector. In particular, the business model of private for-profit nursing homes created a strong incentive for private companies to focus on the maximalization of shareholder value, rather than focusing on the quality of (public) services rendered (and through this, to the extent that public funding was used to pay for the costs of the stay, taxpayer value). Also according to the findings of these authors, shareholder value maximalisation was in many cases achieved by reducing costs connected to the provision of the nursing or care services itself. Some of these methods for maximizing shareholders’ value were fairly standard, albeit still damaging to society, such as tax avoidance, and putting a downward pressure on wages.¹¹³

Quality of care clearly took a hit in the United Kingdom. From the IPPR research regarding the situation in the United Kingdom in September 2019 (cf. Sect. 6.1.1.4.1), it even appeared that in private nursing homes, which by then accounted for 84% of all nursing home beds, fewer older people received help with basic tasks, such as washing and dressing, than had been the case in 2010. This was mainly attributed to cuts.¹¹⁴

6.2.1.2 Covid-19 Hitting the Sector of the EU Nursing Homes Hard

6.2.1.2.1 General Unpreparedness of the EU Nursing Homes Sector

When the Covid-19 epidemic struck in the EU in March 2020, the nursing home sector in the EU had hardly any preparatory measures in place: There were, in many cases, no contingency or emergency plans, no stocks of protective equipment, no protocols on how to respond to an epidemic or pandemic, no measures regarding visitors, etc.¹¹⁵ Stevis-Gridneff, Apuzzo and Pronczuk even made the suggestion that public health officials around the world largely and deliberately excluded long-term nursing homes from their pandemic preparedness plans, and simply omitted nursing home residents from the mathematical models they used to guide their policy responses.¹¹⁶

In the opinion of Stevis-Gridneff, Apuzzo and Pronczuk, of the countless missteps made by neoliberal governments around the world during the Covid-19 pandemic, few have had such a devastating impact as the complete failure of the EU and its Member States to protect EU long-term nursing homes and their residents. This complete failure of leadership is one of the main reasons why tens of thousands of elderly people in long-term nursing homes were abandoned to die, victims not only of the Covid-19 virus itself, but also of more than a decade of ignored warnings on the vulnerability of long-term nursing homes under neoliberal austerity.¹¹⁷

Moreover, the complete absence of dedicated surveillance systems and the huge differences in testing strategies and capacities, if at all available, between EU member countries may even imply a significant underestimation and underreporting of both the number of contamination cases, as well as Covid-19 related deaths. Especially during the first wave of the Covid-19 pandemic, the latter element most likely resulted in a general underestimation of both the contamination cases and Covid-19 related mortality rates in the long-term nursing homes for the elderly.¹¹⁸

Be that as it may, even if the actual death toll has been undercounted, European countries were still world leaders in per capita deaths due to Covid-19, a death toll largely attributable to what was happening in long-term nursing homes.¹¹⁹

6.2.1.2.2 Some Elementary Numbers

Already early in the Covid-19 pandemic, Covid-19 has been found to have disproportionately affected older age groups across the WHO European Region - in the early months, people aged 50 and over accounted for about 70% of Covid-19 contamination cases and almost 100% of deaths from Covid-19. However, over the course of the pandemic, and as testing expanded, these numbers would change. By the end of 2020, almost 60% of all Covid-19 infections occurred in people aged 5–48, while those aged 50 and over still accounted for a large proportion of Covid-19 related deaths.¹²⁰

Especially from March 2020 onwards, the impact of Covid-19 on long-term care nursing homes for the elderly proved to be more than disastrous. A large proportion of these nursing homes across Europe—and globally—immediately began reporting severe Covid-19 outbreaks, with high rates of resident morbidity and mortality, in addition to high staff absenteeism because of Covid-19 symptoms. The transmission dynamics of Covid-19, combined with the low availability of testing, had led to a rapid spread within and between long-term nursing home facilities. This was believed to have resulted into high numbers of deaths among nursing home residents.¹²¹

According to Hall, Chazan, et al., at least two of France’s big private healthcare enterprises had received early warning of the pending global Covid-19 disaster thanks to their operations in China. Said authors quoted Jean-Claude Brdenk, at the time CEO of Orpea—the world’s largest private operator of long-term nursing homes that also runs a long-term nursing home south of Wuhan—in saying that Orpea had been warned by its Chinese teams as early as late January 2020 that a “Sars-type” disease had been rampant in Wuhan. Orpea, which at the time employed a 65,000 staff around the world, in response to this information began closing its 240 French Ehpads to visitors already a week before the French government ordered its first Covid-19 containment measures. Still according to Hall, Chazan, et al., Orpea also organized staff training, issued protocols, sought supplies of medical protective equipment and, in general, braced itself. Yet, even the people living in Orpea nursing homes were not spared. On 12 March 2021, the first positive case in an Orpea nursing home was reported. In total, 2600 of France’s 18,500 Orpea inhabitants were reportedly contaminated with Covid-19, 416 of whom died between the beginning of March 2020 and the end of July 2021. After that time, Orpea reported only 16 more Covid-19 deaths.¹²²

In Sweden, overburdened emergency doctors acknowledged that they simply refused elderly patients.¹²³

In the United Kingdom, the government was reported of having send thousands of elderly hospital patients—including some with Covid-19—back to their nursing homes to make space for an expected increase in Covid-19 cases among the rest of the population.¹²⁴

A similar policy was put in place in some US states.¹²⁵

The figures from early May 2020, shortly after the first wave of Covid-19 was slowed down, speak for themselves.

France had set up a special reporting system for Covid-19 in nursing homes. Between 1 March and 11 May 2020, 7469 facilities had reported Covid-19 cases, of which 4367 (66%) had been in long-term nursing homes for the elderly and 2245 (34%) in other nursing homes, such as facilities for the disabled, or for children and young adults. Of the 73,435 reported confirmed and probable Covid-19 contamination cases among residents between 1 March 2020 and 11 May 2020, 13,539 (17%) died, including 3321 in hospitals and 9501 in nursing facilities, representing 50% of all deaths. In addition, 39,294 cases of contamination were reported among staff members.¹²⁶ As of mid-October 2020, 10,856 of the 33,037 Covid-19-related deaths had occurred in nursing homes, according to statistics.¹²⁷

As of 17 May 2020, Germany had reported 22,071 contamination cases from long-term nursing homes for the elderly, disabled, homeless, migrants or people in prisons. Of these, 8536 cases had been among members of staff (of which 42 had died) and 14,740 cases among residents. Of the residents, 2966 (amounting to 20%) had died, which accounted for 37% of all 7914 deaths related to Covid-19 at that time in Germany.¹²⁸

Ireland also had a specific outbreak notification system for all infectious diseases, which was used to measure Covid-19 cases during the Covid-19 pandemic. As of 9 May 2020, 418 outbreaks of Covid-19 had been reported in long-term nursing facilities in Ireland (including retirement homes, direct care centres and private homes), with 5698 laboratory-confirmed cases and 727 confirmed deaths associated with these outbreaks.¹²⁹

In Norway, 136 (or 61%) of all 224 deaths due to Covid-19 reported up to 11 May 2020 had occurred in nursing homes or other care institutions.¹³⁰

In Sweden, 212 of the +/− 400 nursing homes in the Stockholm area had reported 1711 cases of Covid-19 as of 11 May 2020, which is 630 (45%) of the 1406 deaths due to Covid-19 in Stockholm. In Stockholm County, 400 nursing homes participated in a survey during the period 12–15 April 2020, with 212 (53%) of them reporting that they had confirmed Covid-19 cases. Of these 212 nursing homes, 123 reported the extent of their outbreaks, with 37% reporting 4–10 cases, and 22% >10 cases. In Sweden, 541 nursing homes were affected and 2866 confirmed Covid-19 cases, with 948 deaths, were reported in residents of nursing homes older than 70 years, amounting to 50% of all Covid-19-related deaths for this age group.¹³¹

In the United Kingdom, the “Office for National Statistics” listed 6997 (21%) nursing home deaths as Covid-19-related in mid-May 2020, out of a total of 33,337 registered Covid-19 deaths in England, and 404 (25%) nursing home deaths, out of a total of 1641 Covid-19 deaths in Wales between 28 December 2019 and 1 May and 9 May 2020, respectively. The “Care Quality Commission” listed 8314 nursing home deaths related to Covid-19, as reported between 10 April 2020 and 8 May 2020, in England, and 350 nursing home deaths in Wales.¹³²

As of 17 May 2020, Scotland indicated that 632 (58%) of the long-term nursing homes for elderly people had reported at least one presumable Covid-19 contamination case, and 463 more than one case of Covid-19, with 5096 possible cases in total. By 10 May 2020, 1438 Covid-19-related deaths had been reported from nursing homes, accounting for 45% of all 3213 Covid-19 related deaths.¹³³

It has been calculated that only about a third of European nursing homes had infection control teams in place before the Covid-19 pandemic. Most did not have in-house doctors, and many did not have arrangements with external doctors to coordinate care.¹³⁴

An important factor that helps explaining the spread of Covid-19 within Europe’s long-term nursing homes was related to staff continuing working while infected, including symptomatic, pre-symptomatic and asymptomatic cases. Other contributing factors may have been the fact that many members of staff worked in more than one long-term nursing facility, besides a lack of personal protective equipment (PPE), a lack of training and testing, and the fact that in many nursing homes, testing had been kept limited to symptomatic individuals. Limited testing may also have played an important role in underestimating cases. In addition, the high prevalence of neurological disorders, such as dementia and neuropathic conditions, among nursing home residents may have led to atypical clinical presentations of Covid-19, or the absence of obvious signs or symptoms until the patients’ condition had worsened.¹³⁵

In general, European leaders, by fixating on saving their hospitals, often abandoned long-term nursing homes and their staff to their fate,¹³⁶ with disastrous consequences.¹³⁷

According to the Corporate Europe Observatory, the consequences of the Covid-19 pandemic will be felt for a long time to come: It is in all our interests to confront the interests and ideologies that have been all too successful in transferring public health care into private hands for profit.¹³⁸

6.2.1.3 Covid-19 Hitting the Nursing Homes of Some Countries

6.2.1.3.1 The Disastrous Impact of Covid-19 on the Belgian Nursing Homes

In the opinion of Stevis-Gridneff, Apuzzo and Pronczuk, few countries epitomise the fatally inefficient response to Covid-19 in their long-term nursing homes more than Belgium, where:¹³⁹

• 1. Government officials bluntly excluded nursing home residents from their testing policy until thousands of them had already died.

• 2. Long-term nursing homes had to wait months for the right face masks and protective gowns.

• 3. When face masks ultimately arrived, they came fare too late and were often themselves either flawed or even outright dangerous.

• 4. Probably worse, during the first wave of the Covid-19 pandemic, nursing home residents were systematically denied access to hospitals, which in many cases meant that they were simply left to die.

Since Belgium is Belgium, it should come as no surprise that when Covid-19 struck, some of the abandoned directors of Belgian long-term nursing homes resorted to the strangest methods in their fight to keep Covid-19 out of their homes. One director of a nursing home, faced with no other alternatives, ordered thousands of ponchos after having seen animal-keepers wearing them in a zoo in the countryside. Another nursing home managed to get 5000 decent face masks through a staff member’s father who lived in Vietnam. The precious cargo was reported to have arrived via the Vietnamese embassy’s diplomatic pouch.¹⁴⁰

In subsequent interviews, Belgian officials stated that refusing decent care to the elderly residing in nursing homes had never been part of an explicit or deliberate policy. In the best of Belgian traditions, things had just happened in the absence of a clear national strategy for dealing with the Covid-19 pandemic, and with regional ministers and other policymakers squabbling over who was in charge. Officials of all possible levels later simply acknowledged that most hospitals and emergency services had to rely on vague advice and guidelines on how to deal with the residents of long-term nursing homes. In many cases, this amounted to simply ignoring their existence and letting them die where they were.¹⁴¹

In March 2020, the situation in many of Belgium’s long-term nursing homes was so dire that the medical charity and NGO “Artsen zonder Grenzen”/” Médecins Sans Frontières” decided to dispatch teams of its medical experts, who usually work in war-torn countries in remote and underdeveloped regions, to Belgium itself.¹⁴² Médecins Sans Frontières (“MSF”) (or, in English: “Doctors Without Borders”) thus undertook a first series of emergency interventions in nursing homes in Brussels, on 21 March 2020, and on later dates in Flanders and Wallonia as well. In addition, MSF established a crisis centre in Brussels in order to provide care to homeless people and migrants with Covid-19 symptoms. MSF, furthermore, started to provide technical assistance, as well as training to hospitals and convalescence homes.¹⁴³

MSF’s aid to long-term nursing homes involved deploying mobile assistance teams, that usually consisted of a nurse, a health promoter and, if necessary, a psychologist. These emergency assistance teams were meant to provide technical expertise and training, aimed at increasing the capacity of nursing home staff, for dealing with matters like: infection prevention and control (IPC), organisation of care, testing, classification of nursing home residents into cohorts in accordance with their infection status, besides assistance in restarting activities through lockdowns. As the extreme needs of the Belgian nursing homes became more and more apparent, psychosocial support for the staff members of nursing homes soon became a substantial part of the emergency assistance teams’ normal tasks.¹⁴⁴

An MSF intervention usually consisted of a first visit in order to meet with the head and other key staff members of the nursing home concerned and to assess the situation in said nursing home. Upon such a visit, the MSF assistance team then provided tailored recommendations for the specific circumstances of the nursing home concerned, while afterwards continuing to provide support through follow-up calls and, if necessary, additional visits with the aim of providing further training to staff members. The MSF also developed learning materials created specifically for Covid-19 settings, such as posters, videos, training courses and webinars on a wide variety of topics ranging from IPC measures, screening, mental health, to easing lockdown measures. This information was made available and distributed via websites to reach a broader audience than could be reached through physical support visits.¹⁴⁵

MSF reported that in total 135 Belgian nursing homes benefited from such physical support visits (81 out of a total of 138 nursing homes in the Brussels region, 33/602 in Wallonia and 21/821 in Flanders), with a total of over 3000 staff receiving such advice and practical support from MSF. Specific support requested from the mobile, emergency assistance teams was diverse and, in most cases, reflected the actual challenges and needs faced by the nursing home staff members in adapting to Covid-19, as well as to the changing overall response. An initial MSF visit often served to listen and provide an emotional debrief to the nursing homes management, as well as for providing feedback on the contamination prevention measures already in place within the facility, and even for providing some general reassurance.¹⁴⁶

To illustrate the extent of the extreme scenarios the MSF emergency assistance teams had to deal with, reference can be made to the following quote from an article that appeared in The New York Times from the hand of Stevis-Gridneff, Apuzzo and Pronczuk¹⁴⁷:

On March 25, [2020] when a team arrived at Val des Fleurs, a public nursing home a few miles from European Union headquarters, they were greeted by the stale smell of disinfectant and an eerie stillness, pierced only by the song of a caged canary.

Some staff members showed signs of trauma common in disaster zones, the medical charity found.

When the M.S.F. team arrived, both the director and her deputy were sick with Covid-19.

Seventeen people had died there in the past 10 days. There was no protective equipment. Oxygen was running low. Half the staff was infected. Others showed signs of trauma common in disaster zones, a psychologist from the medical charity concluded.

The director and her deputy were sick with Covid-19, and the acting chief collapsed in a chair, crying, as soon as the team met her.

“I never thought I would work with M.S.F. in my own country. That’s crazy. We are a rich country,” said Marine Tondeur, a Belgian nurse who has worked in South Sudan and Haiti.

Ms. Tondeur was horrified at her country’s response.

“I feel a bit ashamed, actually, that we forgot those homes.”

In February 2020, when Covid-19 took root in northern Italy, Belgian officials had still shown little concern. Maggie De Block, Belgium’s federal health minister, had been continuously downplaying the risk of Covid-19 for an entire month. Although trained as a medical physician herself, she did not consider it necessary to worry about hospital capacity or testing options. She was, by contrast, convinced that Covid-19 would be no worse than a seasonal flu.¹⁴⁸ (Cf. Sect. 2.4.2.3.6., on Belgium’s initial reaction to Covid-19.)

Even after the WHO had pointed out the importance of drawing up plans for protecting long-term nursing homes, a spokesman of the health authority of the Dutch-speaking region of Flanders had still declared that there was no reason for concern whatsoever. Yet all warning signs were at the time present: To start with, Belgium was characterised by one of the world’s largest long-term nursing home populations per capita (cf. Sect. 6.1.1.4.5). In addition, it was a well-known fact, backed by years of scientific research, that respiratory diseases, such as Covid-19 itself, were among the most common illnesses occurring in long-term nursing facilities for the elderly. Data on China, which by then had been made public to the entire global community, had, furthermore, clearly shown that the elderly residing in nursing homes were among those at greatest risk of dying from Covid-19. Finally, internal government reports dating back as far as 2006 had already called for more training on infectious diseases for nursing home doctors, as well as for more government support for stockpiling of protective equipment. Another report dating from 2009, similarly recommended that long-term nursing homes had to be included in Belgium’s pandemic plan. However, both these proposals had never been acted upon.¹⁴⁹

All of this implied that, at the beginning of March 2020, when Covid-19 started hitting Belgium, Belgian long-term nursing homes were basically left on their own. In the official emergency documents with regard Belgium’s internal risk assessment, long-term nursing homes were not even mentioned as one of the country’s major concerns.¹⁵⁰

According to MSF evaluations during their visits to Belgian nursing homes, just over half of the Belgian long-term nursing homes (54%) had sufficient protective gowns, only 64% had sufficient FFP2 masks, and only 42% of staff members in charge of laundry had appropriate PPE protective equipment at their disposal. More than one out of six long-term nursing homes that had been paid a visit by an MSF emergency assistance unit did not have disinfectants capable of killing Covid-19 at their disposal, while the means for disinfecting medical equipment was inadequate in 19% of all cases. In addition, a mere 53% of the long-term nursing homes felt that their staff members were sufficiently aware of the dangers posed by Covid-19 and its contamination risk. More than three out of ten nursing homes had declared not to conduct any Covid-19 screening at all; only 78% of all nursing homes reported to isolate plausible Covid-19 contamination cases in separate rooms, while more effective isolation or cohort formation of confirmed Covid-19 contamination cases had only taken place in 60% of the cases. Systematic therapeutic plans and end-of-life arrangements had only been available in seven in ten nursing home facilities.¹⁵¹

Many other problems the Belgian long-term nursing homes had been facing, were caused by the completely inefficient administration of Belgium itself. Belgium is divided by languages and has already for decades been extremely difficult to govern. In the opinion of Stevis-Gridneff, Apuzzo and Pronczuk, Belgium has so many layers of bureaucracy that foreigners sometimes call it an “administrative lasagne”. At the beginning of March 2020, Belgium had not one, but—depending on the manner of counting—eight¹⁵² or nine¹⁵³ ministers of health, answerable to six different parliaments. While the federal government is supposed to play a coordinating role in the event of a pandemic, healthcare facilities in general, and nursing homes in particular, fall under the remit of the regional authorities. So even when Belgian officials had finally become aware of the threat posed by Covid-19, they could not act decisively until they had determined which of them was (most) responsible.¹⁵⁴

By mid-March 2020, when Covid-19 was spreading rapidly across Europe, the Belgian regional governments started advising nursing homes, but remained unhelpful in key areas. E.g., at a certain point in time, government documents started emphasising the importance of face masks, while at the same time stating that they were virtually unavailable,¹⁵⁵ as shortly before the Covid-19 outbreak, the Belgian Federal Minister of Health Maggie De Block had given the order to destroy the Belgian stock, without having taken measures to replace them. Worse still, Belgium was at that time also unable to test even a small fraction of infected persons. The health authorities had, therefore, decided to test only seriously ill, hospitalised patients. All others were simply told to recover at home. For the elderly, this policy implied that infected elderly people were told to remain in or go back to overcrowded, understaffed, inadequately equipped and unprotected nursing homes.¹⁵⁶

When Belgium closed down on 18 March 2020, dozens of residents of long-term nursing homes had already died.¹⁵⁷

There was overall no policy whatsoever for isolating the elderly. Later, it turned out that this had been another decisive factor in the high number of Covid-19 contamination cases and deaths in the Belgian nursing homes for the elderly.

Let us again quote from the article that appeared in the New York Times from the hand of Stevis-Gridneff, Apuzzo and Pronczuk:¹⁵⁸

Belgium went into lockdown on March 18. Dozens of nursing-home residents had already died. Three days later, Jacqueline Van Peteghem, a 91-year-old resident at the Christalain home, was sent to UZ Brussel, a nearby hospital, where she was tested for Covid-19. Within days, her test came back positive.

Shirley and Steve Doyen assumed Ms. Van Peteghem would remain hospitalized for treatment and to prevent the disease from spreading to scores of other residents. But her symptoms had stabilized, and Mr. Doyen said that a hospital doctor declared her healthy enough to return home.

So, on March 27, paramedics in hazmat suits delivered Ms. Van Peteghem, on a stretcher, to the door of Christalain.

Mr. Doyen greeted them wearing a surgical mask.

“Is this mask all you have?” the paramedics asked, Mr. Doyen recalled.

“Yes,” he said.

“Good luck,” they responded.

For the next hour, Christalain staff members watched as the paramedics decontaminated themselves and their ambulance. Asked later about the hospital’s policies, the chief executive, Prof. Marc Noppen, said infectious patients were not normally returned to nursing homes but that it may have happened in some cases.

No one can be certain if Ms. Van Peteghem’s return was the reason, but Covid-19 infections in the home increased. Residents began dying. Ms. Van Peteghem, who initially survived the virus, died last month.

According to Stevis-Gridneff, Apuzzo and Pronczuk, the Belgian authorities were well aware of these and similar problems, as appeared from internal documents. “Some patients have returned from the hospital infected,” a government emergency committee was quoted having written on 25 March 2020. “Several hot spots have been caused this way.” In response to these problems, the emergency committee simply recommended testing nursing-home residents more, besides installing locations to house Covid-19 patients who otherwise would have been sent to their private or nursing homes.¹⁵⁹

Despite everything that went wrong, Belgium’s national and regional authorities still could not agree on clear recommendations for long-term nursing homes, and so—not unusual for Belgium—a mishmash of conflicting policies emerged.¹⁶⁰

For another 2 weeks, while the Belgian government was finally starting to expand the country’s testing capacity, specialised health advisers continued to oppose the addition of long-term nursing homes to the national priority list for testing. Said health advisors expressed their concern that even the country’s new and expanded testing capacity would not be able to meet the demand of such expanded criteria (again according to official documents and government officials referred to by Stevis-Gridneff, Apuzzo and Pronczuk.)¹⁶¹

Ultimately, testing in long-term nursing homes began on 8 April 2020. When the first testing results were made public, one in five nursing home residents tested positive for Covid-19. At that moment, over 2000 nursing home residents had died already.¹⁶² By 5 May 2020—2 months after Belgian authorities had shown first signs of taking Covid-19 more seriously—systematic testing of all residents and staff in a selection of Belgian long-term nursing homes with confirmed Covid-19 cases demonstrated that 73% (5695/7751) of PCR-tested positive cases had been asymptomatic.¹⁶³ As of 16 May 2020, 51% of the by then 9052 Covid-19-related fatalities had been identified as nursing home residents, with only 23% of these cases confirmed by laboratory testing. Further systematic testing for SARS-CoV-2 among all nursing home residents showed that 4% (5640/141,089) were positive for Covid-19 and more often symptomatic than asymptomatic (25% and 3%, respectively). Testing was then also conducted on nursing home staff members, which resulted in 3106/136,282 (or more than 2%) testing positive for Covid-19. Overall test positivity for Covid-19 was higher among symptomatic than among asymptomatic staff members (11%, and 2%, respectively). However, the total number of asymptomatic cases among both nursing home residents and nursing home staff members amounted to 75% (6540/8746) of all cases that had tested positive for Covid-19 at these facilities.¹⁶⁴

As the test debate unfolded as of late March and early April 2020, Belgian hospital physicians quietly stopped accepting Covid-19 patients from nursing homes. This policy—although officially qualified as a mere “advice”—took shape in a series of memos originating from Belgian geriatric specialists. According to these memos, extremely vulnerable and terminally ill patients were only entitled to receiving palliative care and were not to be admitted at the hospitals.¹⁶⁵

It is hereby assumed that, by then, the priority of Belgian politicians and policymakers had become to keep overall hospital capacity, at all cost, available for coping with an influx of “regular” (i.e., younger) patients and, thereby, to avoid a worst-case scenario of overcrowded hospitals like the one that had occurred in Italy or Spain. However, according to a report by “Médecins Sans Frontières”, this policy at the same time implied that the residents and the staff members in communal housing, such as long-term nursing homes for the elderly or disabled, were simply abandoned to fend for themselves. According to one source, paramedics had even been instructed by their corresponding hospitals not to provide transport services to patients above a certain age, often 75, but sometimes as low as 65. It has even been suggested that high-ranking regional and national officials were fully aware of this policy.¹⁶⁶ Be this as it may, the result of this policy has been that in such long-term care facilities, living quarters had to be turned into improvised hospitals, which obviously lacked all elementary protective and other medical equipment, as well as both sufficient and sufficiently qualified health personnel to wage the unprecedented fight against Covid-19, and/or the knowledge of how to control an epidemic or pandemic in an artificially closed environment.¹⁶⁷

Belgian nursing home residents with Covid-19 symptoms arriving at hospitals were time and again refused entry, even in cases where they had been referred by physicians who had diagnosed them as possibly infected, but likely to recover, and therefore had recommended to bring them to a hospital. There are no official data on how often this practice has been resorted to by Belgian hospitals, but “Médecins Sans Frontières” noted that about 30 percent of the long-term nursing homes it had worked in during its deployment in Belgium, had formally reported this problem.¹⁶⁸

Government figures, furthermore, speak for themselves. In the first weeks of the Covid-19 crisis, almost two-thirds of the fatalities among nursing home residents took place in hospitals. But when the Covid-19 crisis erupted in full force, and the abovementioned geriatric advisory notes started to circulate within hospitals, that number suddenly dropped. At the height of (the first wave of) the Covid-19 outbreak, only 14% of critically ill nursing home residents still made it to hospital. The rest were abandoned to die in their nursing home, according to official government data collected by Belgian scientists.¹⁶⁹ Before the Covid-19 crisis, the referral of nursing home residents to external medical services amounted to 86%. During the Covid-19 crisis, this number dropped to 57%. Among the long-term nursing homes visited by the MSF emergency assistance teams, just over 70% still received emergency medical intervention if called for. The number of visits by GPs (general practitioners) compared to the period before the Covid-19 crisis, was said to be down by half, which obviously had a huge impact on the medical treatment of nursing home residents, both for Covid-19 symptoms, and various other health problems.¹⁷⁰

In the opinion of Molenberghs et al., is impossible to estimate how many deaths were preventable. However, it was later reported that during the period that nursing home residents were systematically denied admittance, hospitals always had had available space. Even at the height of the first wave of the Covid-19 pandemic, 1100 of Belgium’s 2400 ICU beds had remained free, according to Niel Hens, government adviser and professor at the University of Antwerp (as quoted by Molenberghs et al.).¹⁷¹

The emergency assistance teams of Médecins Sans Frontières ended their special nursing home missions in Belgium by mid-June 2020. Some of these team members returned to developing countries. Others went to work in another rich country facing a health crisis due to neoliberal austerity policy: the United States.¹⁷²

In an interview on 28 May 2020, Maggie De Block, Belgium’s Federal Minister of Health and, as said, a medical doctor herself, testified about the long-term nursing homes as if they were but an unfortunate detail in an otherwise successful story of government action. The Minister thereby proudly remarked that Belgium had never faced a shortage of hospital (ICU) beds.¹⁷³

The assessment of MSF, on the other hand, was muted:¹⁷⁴

As in many other countries, elderly populations – too frail and old to be a priority – have been overlooked in the emergency response. It is high time that these individuals, and the nursing home staff who have been stretched to the limit, were given the status and respect they deserve, and that action be urgently taken.

By July 2020, the Covid-19 pandemic in Belgium had caused 9731 deaths, mainly because of the disastrous handling of the pandemic by the authorities. Even more worryingly, 64% of these deaths had occurred among residents of long-term nursing homes, and a large proportion (almost 4900) of these deaths had occurred within the walls of these facilities themselves, in many cases under the most appalling conditions.¹⁷⁵

6.2.1.3.2 Spain

6.2.1.3.2.1 Finding the Dead in Nursing Home Beds

At the time of the Covid-19 outbreak, around 75% of the long-term nursing homes in Spain were privately run, although many residents received public funding in order to finance their stay. During the first wave of the Covid-19 pandemic, the army had to be deployed in order to decontaminate 1300 besieged long-term nursing homes located in Madrid, with disturbing reports of residents being found “dead in their beds” where they had simply been left to die.¹⁷⁶

In the Corporate Europe Observatory-report already referred to before, the Patients Defenders group’s ombudsman is quoted describing how private long-term nursing homes had already long before the Covid-19-crisis struggled “to carry out savings somewhere to make a profit”, further illustrated by a systematic lack of protective equipment and qualified staff. According to an investigation by the BBC, as again quoted by the Corporate Europe Observatory, relatives of residents from the Spanish nursing homes had found that even symptomatic patients had not been put in isolation, and that sick staff members had not been redeployed, which had left the remaining staff members on longer, exhausting shifts while they had no protective material at their disposal.¹⁷⁷ Meanwhile, overcrowded hospitals, faced with a shortage of beds, were forced to turn incoming Covid-19 patients from nursing homes away, while further governmental guidelines were issued in which the nursing homes themselves were instructed not to refer residents suffering from Covid-19 to hospital.¹⁷⁸

In a report from December 2020, Amnesty International observed that the elderly were denied their right to health, as a result of austerity measures and the underfunding this had caused in Spanish healthcare.¹⁷⁹

From the Amnesty International Spain’s December 2020 report titled “Abandoned: The lack of protection and discrimination against older people in care homes during the COVID-19 pandemic in Spain”, it appeared in general terms that the measures resorted to by the Spanish authorities for fighting the Covid-19 crisis in Catalonia and Madrid, had been mostly both ineffective and insufficient. In addition, these measures themselves reportedly breached at least five human rights of long-term care home residents.¹⁸⁰ The Amnesty International report, furthermore, indicated that a decade of cuts in healthcare and social services had completely undermined the Spanish public health system and that this had worsened access, affordability and quality of health care. Amnesty International underlined that, while most elderly people in Spain were living in private (and often subsidized) retirement homes, this in no way detracted from the State’s obligation to ensure the protection of their human rights, including against corporate abuses. In this viewpoint, the far-reaching privatisation of health care and care for the elderly does not diminish the State’s obligation to protect its people, especially if this care is still subsided through public money. Still, it even seems that the lessons taught by the first wave of the Covid-19 pandemic were not at all learned. Too many mistakes were inexcusably repeated during the subsequent waves of the Covid-19 pandemic.¹⁸¹

According to Esteban Beltrán, director of Amnesty International in Spain, the human rights that had been violated during the Covid-19 pandemic were: (1) the right to health, (2) the right to life, (3) the right to non-discriminatory treatment, (4) the right to a private and family life, and (5) the right to a dignified death for elderly people.¹⁸²

Especially the denial of the right to health was seen as the result of years of austerity measures and underfunding of the healthcare sector in Spain. A decade of cuts in health and social services was thereby said to have completely undermined the public health system and worsened its accessibility, affordability and quality.¹⁸³

The consequences of undermining the public health care system have in particular been experienced in the long-term nursing homes in Madrid and Catalonia during the culmination point of the first wave of the Covid-19 pandemic (i.e., in March and early April 2020). This was felt in several ways: on the one hand, there was a complete lack of equipment for protecting the staff members of the Spanish nursing homes, who had not been handed out any personal protective equipment (PPE) and who had no access to PCR or other Covid-19 tests. When the Covid-19 pandemic broke out in mid-March 2020, nursing home staff members thus resorted to making their own PPE, from anything they could find, ranging from jackets, rubbish bags, pantyhoses, plastic caps…¹⁸⁴ On the other hand, a huge number of long-term nursing home residents did not get access to adequate medical care. Residents were generally excluded from referrals and admittance to hospitals and did, moreover, not receive the medical help they desperately needed in their nursing homes either, all of this despite the “medicalisation” of the nursing home sector that had been proudly announced by the Spanish authorities. In addition, many long-term nursing home residents were completely cut off from the outside world, as well as from their families, for several weeks.¹⁸⁵

To make things even worse, a lot of these human rights infringements were repeated during the second wave of the Covid-19 pandemic, notwithstanding efforts for improvement in some areas. E.g., family visits could still not be guaranteed in full during the second wave of the pandemic which, in practice, implied that they depended on the good will of individual nursing home staff members. In addition, the regulations on the Madrid and Catalonia hospital referral protocols, kept insisting that Covid-19 contaminated nursing home residents had to be treated in their nursing homes, rather than being transferred to hospitals. Moreover, no adequate measures were taken to increase levels of staff members for nursing homes to meet the needs that arose in light of the high pressure that the Covid-19 crisis put on healthcare services in general.¹⁸⁶

According to the Vice-President of the “Spanish Society of Geriatrics and Gerontology” (abbreviated as “SEGG”), Spain had not been sufficiently prepared for the Covid-19 pandemic, had ignored all scientific information originating from other countries, and had resorted to countermeasures far too late. During the pandemic itself, little further progress was made with regard to informing and training nursing home staff members.¹⁸⁷ The measures adopted by the “Autonomous Community” of Madrid and by the local Government of Catalonia (i.e., the “Generalitat”) were conceptually flawed and implemented in an ineffective manner. Said authorities, moreover, adopted diverging measures which added even further to the confusion. The measures were not very helpful either, as, e.g., they did not contain clear criteria for dealing with contaminated people. There was, moreover, little or no follow-up. Thus, the measures failed to ensure adequate healthcare and medical services for the elderly stuck in nursing homes.¹⁸⁸

A lack of qualified staff and resources to adequately fight the Covid-19 pandemic, combined with the mandated isolation of nursing home residents, thus resulted in a marked deterioration of the general health situation among nursing home residents.¹⁸⁹

In the assessment of Amnesty International, one of the further reasons why the Covid-19 virus was able to spread so easily and quickly in the Spanish long-term nursing homes was that the undermanned nursing staff had to be in constant contact with all nursing home residents, while they themselves had no access to any protection material. This lack of protection also led to a large number of contaminations and deaths among staff, which diminished the numbers of available personnel even more, thus resulting in a further negative impact on the way elderly people residing in nursing homes were cared for, besides on the management of health care in general.¹⁹⁰

The decision not to refer or admit sick elderly people to hospitals was, moreover, implemented in a rigid, automated manner, with little or no margin for carrying out individual assessments. As a result, most elderly nursing home residents could not get treatment for either Covid-19 infections or any other pathology they suffered from, neither in hospitals nor in the nursing homes themselves. Meanwhile, authorities kept announcing the opposite. Furthermore, in both of the above-mentioned autonomous regions, there were hardly any hospitalization admissions of nursing home residents. The very few referrals that did take place were exceptions to this general practice, and in many cases suffered from fatal delays as well. Amnesty International has qualified this practice as discriminatory and, therefore, as a most fundamental breach of the human rights of the elderly people concerned. In addition, Amnesty International gathered testimonies from which it appeared that the emergency ambulance services (SUMMA and SEM) resorted (and had to resort) to similar discriminatory practices.¹⁹¹ According to Amnesty International, there were even documented cases of nursing home residents suffering from dehydration and malnutrition.¹⁹²

At the height of the Covid-19 pandemic, residents in the nursing homes themselves were locked in their rooms for long periods of time, sometimes for several weeks in a row. The restrictions arising from such de facto confinements within the walls of the nursing homes, which in most cases involved locking elderly people up in their individual rooms for indefinite periods of time, was, furthermore, accompanied by a lack of any effective supervision by the national (i.e., the Public Prosecutor’s Office) and regional authorities (i.e., the inspectorates). This implied that the human right of the elderly to a decent private and family life was violated merely because of the place where they lived.¹⁹³

The figures for the elderly who died in nursing homes are far from clear:

• (1) According to the January 2021 report of the Corporate Europe Observatory, by the end of April 2020, 6000 people were reported to have died in nursing homes in Madrid alone after having shown Covid-19 symptoms. According to this report, more than half of all deaths due to Covid-19 in Madrid and Aragón, were among people residing in nursing homes. This number even amounted to 86% in La Rioja (as of March 2020).¹⁹⁴

• (2) According to data released by the Autonomous Community of Madrid itself, in the period from 8 March 2020 to 1 May 2020, 5828 people died in nursing homes due to Covid-19 or compatible symptoms. This number represented 43.46% of the total number of deaths up to that date in the Autonomous Community of Madrid (with said data not broken down by age, gender and/or disability).¹⁹⁵

• (3) In Catalonia, according to data provided by the Catalan Government, in the period from 1 March 2020 to 15 November 2020, 7045 elderly people residing in long-term nursing homes died due to Covid-19 or compatible symptoms. This number accounted for 46.9% of all deaths in Catalonia from Covid-19, which in total amounted to 15,013.¹⁹⁶

• (4) The most detailed figures on the number of victims are probably those which the Spanish government (finally) announced on 3 March 2021 and which we shall examine in more detail below in Sect. 6.2.1.3.2.2.

Business analysts had in the past referred to the Spanish long-term nursing home market as a “resilient (investment) sector”, i.e., one that is highly profitable and thus ripe for private investment. Business opportunities were enhanced by resorting to capitalist practices such as understaffing, employing underqualified staff, underpayment of staff and outsourcing of certain services, all shortcuts that have proven deadly during the Covid-19 pandemic.¹⁹⁷ An investor outlook dealing with the “Elderly Care Market” and published in early 2020 by real estate firm Knight Frank, had referred to the “growing demand for elderly care properties”, with investment volumes “now in excess of €6.5 billion per year”. And it was also made clear why the market for elderly nursing homes was advised as being such an interesting private investment opportunity. According to Knight Frank, pre-tax profit margins for private operators “typically range[d] from 25–35%”, a figure that was to be achieved by rising service fees and ensuring a high occupancy rate, while costs related to staff employment were indicated as representing “the main challenge for operators”.¹⁹⁸

All of this is obviously significant, to the extent that news reports on how Covid-19 impacted Spanish nursing homes, time and again, focused on the following practices which have all contributed to the rapid and easy spread of Covid-19 in Spanish long-term nursing homes:¹⁹⁹

• understaffed residences,

• a lack of sufficiently qualified staff,

• staff not allowed to take sick leave/reimbursement,

• reports of staff members having to take much longer shifts than allowed under labour law,

• staff lacking training,

• staff not receiving PPE,

• staff doing occasional work in multiple nursing homes (in this manner contributing to the spread of the Covid- virus from nursing home to nursing home).

When advertising private investments in the long-term nursing home sector, Knight Frank also pointed to the advantages of Spain’s “largely free market structure” for ensuring a high degree of profitability in the sector.²⁰⁰

When Covid-19 struck in Spain, the French-based “DomusVi” group was the market leader in Spain, owning 135 long-term nursing homes; one of them, in Alcoy, already made the news in March 2020, after 21 people died. By the end of 2020, there had been around 2100 deaths in all DomusVi nursing homes in Spain.²⁰¹

6.2.1.3.2.2 Figures Released on 3 March 2021

Several older studies regarding the numbers of Covid-19 contamination cases and Covid-19 related deaths, had first estimated that around 70% of the Covid-19 related deaths had occurred in long-term nursing homes. Early-December 2020, the central government was expected to publish a report, according to which this percentage would be between 50 and 47%.²⁰² But the exact number of seniors who had died in nursing homes because of Covid-19 remained one of the biggest unknowns of the Covid-19 pandemic in Spain, until, on 3 March 2021, the Spanish government finally released its own official figures. According to data from Spain’s regions, systemized and collated by the Social Rights, Health and Science ministries, 29,408 seniors residing in long-term nursing homes had died due to the Covid-19 virus, or with compatible symptoms, as of February 21, 2021. The official number of Covid-19-related deaths in all social service residences, including those for people with disabilities and for other collectives, was reported to amount to 29,782.²⁰³ This is further illustrated in Table 6.3 which gives an overview of the impact of Covid-19 in senior residences in Spain (from 14 March 2020 until 21 February 2021).

Table 6.3 Impact of Covid-19 in senior residences in Spain (Data from 14 March 2020 to 21 February 2021)^a

The data released on 3 March 2021 essentially confirmed the devastating impact of the pandemic on the vulnerable population of elderly nursing home residents.²⁰⁴

According to the on 3 March 2021 released figures, between March and 22 June 2020, 19,835 seniors in long-term nursing homes had died with a confirmed Covid-19 diagnosis, or with compatible symptoms. This amounted to more than double the number reported between 23 June 2020 and 21 February 2021 which amounted to 9573. In addition, a total of 86,219 Covid-19 contamination cases were confirmed in senior residences since the beginning of the Covid-19 pandemic. Of this number, nearly 69,000 had been detected in 2020. According to the same figures, 23.7% of seniors who had tested positive for Covid-19 in 2020, had died. The real number of fatalities, however, is believed to be much higher, to the extent that, especially during the first wave of the Covid-19 pandemic, many nursing home residents had died without being tested for the Covid-19 virus due to a shortage of tests, as a further result of which they were not included in the official toll. In 2021 so far, 18.7% of the Covid-19 contamination cases in long-term nursing homes for the elderly did not survive the Covid-19 virus.²⁰⁵

According to sources from “Imserso”, three key moments of the Covid-19 pandemic are reflected in these data: The first phase of the Covid-19 pandemic in Spain was between March and June 2020, when the long-term nursing homes for the elderly were among the facilities most severely impacted. Afterward, there had been more resources, information provided by authorities had improved, and there was more preventive work undertaken in said long-term nursing homes themselves. As a result, the impact of the Covid-19 pandemic was reduced, yet still remained serious. There was then a third stage starting at the end of January, 2021, 1 month after Christmas, when the impact of the vaccination drive started to be seen.²⁰⁶

According to the Health Ministry report released on 3 March 2021, Spain recorded more than 70,000 official deaths after a positive Covid-19 infection had been detected. It was however, at the same time, indicated that it was difficult to compare this figure to the total death toll in long-term nursing homes due to a systematic underreporting during the first wave of the Covid-19 pandemic. But comparisons could still be made to the period from June 2020, when Spain’s diagnostic capacity and reporting had started to improve. The Health Ministry thus reported a total of 38,776 Covid-19 fatalities between June 2020 and 21 February 2021. Of this figure, one in four (9782) were registered in long-term nursing homes.²⁰⁷

Madrid recorded the highest number of Covid-19 related deaths in long-term nursing homes, with 6187 fatalities, according to the 3 March 2021 data. Madrid was followed by Catalonia (5418 Covid-19 related fatalities), Castilla y León (3987 Covid-19 related fatalities) and Castilla-La Mancha (2803 Covid-19 related fatalities).²⁰⁸

The data on Covid-19 related deaths in Spain’s long-term nursing homes are, furthermore, believed to reflect the severity of the health crisis Spain had to endure. The healthcare systems in the regions hardest hit by the Covid-19 virus were reported to have been completely overwhelmed, and many senior residents of long-term nursing homes were said to have died without receiving any medical attention at all. As mentioned in the previous Sect. 6.2.1.3.2.1, in Madrid, e.g., there were even official protocols advising against transferring nursing home residents to hospitals.²⁰⁹

The general assessment is that Spanish long-term nursing homes for the elderly had been left on their own until very late. Moreover, the protocols designed by the Health Ministry were designed mainly with hospitals in mind, being of only limited use in nursing homes.²¹⁰ Another factor which helps to explain the huge death toll in Spanish long-term nursing homes is the fact that they grouped over-80s, with lots of pre-existing pathologies together, in places that were vectors of transmission because of the continuous coming and going of workers and the communal life of the residents, with shared spaces and utensils.²¹¹

6.2.1.3.3 The United Kingdom

In the United Kingdom, despite the fact that there had been early warnings of the potentially devastating impact of the Covid-19 virus in long-term nursing homes and their residents, the first wave of the Covid-19 pandemic still led to an extraordinary number of excess deaths among long-term nursing home residents. According to Scobie, the scale of mortality in nursing homes laid bare long-standing problems with nursing home service provision, as well as shortcomings in response to the Covid-19 pandemic itself.²¹²

Covid-19 related deaths in the United Kingdom in general rose sharply as of April 2020, and between mid-March 2020 and mid-June 2020, there had already been 19,286 Covid-19 related deaths among long-term nursing home residents.²¹³ However, the number of deaths unrelated to Covid-19 also rose. In the opinion of Scobie, with hindsight, it is very likely that many of these “unrelated” deaths were also from Covid-19 but had not been identified as such at the time. One reason for this was the limited testing capacity in long-term nursing homes at the time. The novelty of the Covid-19 virus, combined with its different symptoms often shown by older people, had made identifying the Covid-19 disease difficult as well.²¹⁴

When looking at the second wave of the Covid-19 pandemic, Covid-19 death registrations began to increase as of November 2020, rising sharply in the first weeks of 2021. Between 31 October 2020 and 5 February 2021, there were 16,355 Covid-19 related deaths registered among people residing in long-term nursing homes.²¹⁵

According to Scobie, comparing the scale of Covid-19 contamination cases and Covid-19 related deaths between the first and second wave of the Covid-19 pandemic remains challenging, the main reason being that there was so little testing during the early months of the Covid-19 pandemic. However, what is clear is that the burden of the Covid-19 virus has, obviously, fallen much more severely on the residents of long-term nursing homes (compared to the general population) during the first wave of the Covid-19 pandemic. Of the 48,213 Covid-19 related deaths registered between mid-March 2020 and mid-June 2020, 40% had been among long-term nursing home residents—compared with 26% of the 62,250 Covid-19 related deaths registered from 31 October 2020 until 5 February 2021.²¹⁶

Still according to Scobie, the number of so-called “excess deaths” gives a clearer understanding of the overall impact of the Covid-19 pandemic on long-term nursing home residents. This “excess” is the number of deaths above the “expected number” in comparison to the average death-rate of a given number of preceding years. In the United Kingdom, this was obtained by comparing the number of deaths from all causes, with the average number of deaths over the previous 5 years.²¹⁷

The United Kingdom had 35,067 excess deaths during the first 2 months of the Covid-19 pandemic, with 6331 deaths in the week ending 24 April 2020, alone. Between mid-June 2020 and November 2020, the number of deaths of long-term nursing home residents had been at, or below, the average for 2015–2019, and it was only as of mid-December 2020 that death registrations consistently exceeded the average.²¹⁸

Since the beginning of the Covid-19 pandemic, 86% of the deaths of long-term nursing home residents occurred within the walls of the nursing home itself, compared with 84% over the same period for 2015–2019.²¹⁹ Long-term nursing home residents whose deaths involved Covid-19 were, however, more likely to have died while away from the nursing home. Only 75% of this group had died in the nursing home, compared to 90% of patients without the Covid-19 virus. In other words, three in four nursing home residents who died of Covid-19, did so in a nursing home. The remaining residents were likely to have died in hospital. Deaths from other causes included a high proportion of deaths from dementia or Alzheimer’s disease. The lower proportion of these residents who died in the nursing home reflects the limited benefits of hospital treatment at the end of life.²²⁰ The foregoing is further illustrated in Table 6.4 which gives an overview of the place of occurrence of deaths of nursing home residents (from 14 March 2020 until 5 February 2021).

Table 6.4 Place of occurrence of deaths of nursing home residents (deaths registered from 14 March 2020 to 5 February 2021)^a

By contrast, the second wave of the Covid-19 pandemic has seen significant excess deaths and confirmed deaths from Covid-19 across the country. Although nursing home residents have not been entirely protected from this, the disproportionate toll of excess deaths among nursing home residents that had occurred during the first wave of the Covid-19 pandemic, did not take place.²²¹ Figure 6.4 gives an overview of the weekly death numbers in England and Wales during the first year of the pandemic.

Fig. 6.4

Weekly deaths (England and Wales). [Source: Scobie (2021)]

Looking for the reasons of the high death toll among long-term nursing home residents in the United Kingdom, Natasha Curry pointed out that the long-term nursing home sector had already been in a fragile state going into the Covid-19 pandemic and was ill-equipped to cope with a sudden tide of infections caused by an epidemic or pandemic. According to Curry, pre-existing staff shortages, a vast and precarious service provider market, long-standing financial shortfalls, and a lack of robust centralised data about who relied on care, together created a context in which a response to the Covid-19 virus was impossible to coordinate.²²² A slow and uncoordinated response on a national level, furthermore, led to delays in both delivery of PPE supplies and the rollout of Covid-19 testing. The drive to clear hospital beds during the first weeks of the Covid-19 pandemic, in addition, failed to take account of the reality of the settings into which many people were being discharged. Released patients were not always tested before leaving the hospital, and even when their Covid-19 status was known, the discharge wrongly assumed that long-term nursing homes had the space, staff and resources to effectively isolate Covid-19 positive residents.²²³

When the second wave of the Covid-19 pandemic approached, efforts in the United Kingdom were made to roll out faster Covid-19 testing, to deliver more reliable supplies of PPE, and to issue more timely and consistent healthcare advice to the sector, including an advice to reduce staff members working across multiple long-term nursing homes. The extension of the Covid-19 infection control fund until late March 2021 (while initially put in place until September 2020 only) was also a welcome factor for more effectively dealing with the Covid-19 pandemic, as was the pledge to supply the sector with PPE free of charge during the same period.²²⁴

Concerns around the financial stability of a wide variety of long-term nursing homes had already been raised before the Covid-19 pandemic,²²⁵ and the increased costs of PPE and staff sickness, alongside lower occupancy rates, created even more extreme financial pressures. (Cf., furthermore, Sects. 6.1.1.4.1 and 6.2.1.1.2) Although the predicted widespread closure of long-term nursing home providers has not yet occurred, some care organisations only just managed to survive with the increased temporary Covid-19 pandemic support from the government. These might still risk closure in the longer run.²²⁶

6.2.1.4 Aftermath

According to the Corporate Europe Observatory, in July 2020, the “European Public Service Union” (abbreviated as “EPSU”), the “European Disability Forum”, and the “Age Platform Europe” urged the European Parliament to investigate the devastating impact of Covid-19 on the long-term nursing home sector. Said institutions pointed to the contribution of “failed policies and underfunding”, as well as to human rights abuses, general understaffing of the sector, and a lack of preventive safety protocols. In addition, the argument was raised that the lack of personal protective equipment for staff members employed in long-term nursing homes for the elderly and disabled, had not only killed numerous residents, but had also resulted in a large number of casualties among staff members.²²⁷ Given the importance of this letter, parts of it are quoted below:²²⁸

We are addressing you on behalf of EPSU, the European Federation of Public Service Unions that organises more than 3 million workers in health and social services, AGE Platform Europe, the European network of organisations advocating for the rights of older people, and the European Disability Forum (EDF), the umbrella organisation representing 100 million persons with disabilities in Europe. We are writing regarding to the dire situation in long-term care across Europe, and in particular in residential care facilities, as a consequence of the COVID-19 pandemic. In the light of recent, dramatic developments, we call on the European Parliament to launch an investigation to assess the failures in addressing and managing the crisis in this sector. This would include taking into account what aspects of residential settings have made them so vulnerable to this pandemic.

There is mounting evidence from several countries that a large proportion of infections and deaths have occurred in residential services for older people, persons with disabilities and other social service facilities. The World Health Organisation indicated that half of the deaths related to COVID-19 in Europe have so far occurred in residential care and support services. However, this is likely to be just the tip of the iceberg: the idea that deaths in residential care services are somewhat “normal” or “unavoidable,” plus the lacking of proper testing, have led to the refusal in many countries to include those who have died in these services as part of the official statistics on COVID. Nevertheless, death counts for the months of March - April 2020 are significantly higher compared to the average number of deaths from previous years. A number of Member residential care and support services. However, this is likely to be just the tip of the iceberg: the idea that deaths in residential care services are somewhat “normal” or “unavoidable,” plus the lacking of proper testing, have led to the refusal in many countries to include those who have died in these services as part of the official statistics on COVID. Nevertheless, death counts for the months of March–April 2020 are significantly higher compared to the average number of deaths from previous years. A number of member states have refused to consider the situation in long-term care facilities a priority, resulting in significant delays in responding to this crisis and neglect of the needs of workers and users in terms of protective equipment and safety protocols.

The appalling stories that are emerging draw an extremely worrying picture of both long-standing and contextual failures, revealing a serious lack of preparedness as well as a very poor and delayed management of the outbreak. This has contributed to thousands of preventable deaths and infections among those receiving care and workers. This sector has long been neglected and has had very low social and political consideration due to societies’ discriminatory practices towards people in need of care and support. The shortages they face are now more visible than ever before. Workers on the frontline of the fight against COVID-19 have been left exposed by a lack of personal protective equipment, testing kits, training and safety protocols. The exposure of workers to the virus has left many residences critically understaffed, unable to meet basic needs and protect the rights of residents, which has only heightened the risk of fatalities.

To cite just a few examples, in Lombardy, the epicentre of the outbreak in Italy, EPSU’s affiliates have encountered serious and worrying deficiencies in the management of the emergency in care for older people. This was due to lack of protocols and personal protective equipment. In some cases, even where protective equipment was available, staff were not allowed to use it because residents were not showing symptoms. Care staff working in residential care and support services and in home services feel as if they, and the people they care and support, are at the bottom of the list for PPE.

In addition, in many countries, despite the details on the number of doctors and other hospital staff that have fallen on duty, the numbers of care workers dead or infected because of COVID-19 are not gathered. Accurate data on the number of older persons and persons with disabilities living in residential care is almost absent in the EU. This makes the monitoring of their situation and accountability for their wellbeing in times of crisis even more difficult. All these elements combined contribute to an incomplete understanding of the situation.

The EU and all its member states are committed to the UN Convention on the Rights of Persons with Disabilities (CRPD), which includes a commitment to a transition from institutionalised to community-based and independent living. EU funding regulations prohibit the EU from funding institutionalisation of persons with disabilities. Community based, person-centred services too have been critically affected by COVID 19. This has left many persons with disabilities without support, forcing them either to rely on family care, or to turn towards other forms of care in institutions, which have become hotbeds of infection.

(…)

Political institutions need to address this failure: workers and users of care and support services are not second class citizens and it is imperative that an official European inquiry is launched into what has been happening in care services and what lessons we need to learn for the future. We owe it to those receiving care and to workers infected, as well as to the victims, to their families and to everyone in Europe.

European citizens expect of the European Parliament, their only direct representative at EU level, to show concern for what happens to them and to address this blatant and pan-European infringements of their rights. The evidence we put forward points to direct breaches of many of their fundamental Rights enshrined in the EU’s Charter of Fundamental Rights—first and foremost their rights to life, dignity and health. For this reason we appeal to you to ensure that the European Parliament hears the voices and concerns of millions of citizens, workers and families: we need you to take a stand and make full use of the Parliament’s powers. A European investigation, via an inquiry committee or a special committee with full investigative powers, would be able to independently verify and assess the preparedness plans and the management of the outbreak in the care sector while providing critical information for future decisions and measures to ensure that this will not happen again.

(…)

Hall, Chazan, et al., have partly nuanced this kind of assessment. According to these authors, a variety of French physicians, caregivers and government officials have privately urged that the tragedy of the Covid-19 pandemic among the elderly must be put more into perspective. In the opinion of these authors, in an average year, about 180,000 of the 700,000 people residing in France’s long-term nursing homes die from influenza and similar causes. According to the same authors (who thereto referred to information from the statistical institute “Insee”), France’s highest daily mortality rate during the deadly 2003 heat wave, by far exceeded the worst days of the Covid-19 pandemic in March and April 2020. This argument, of course, makes little sense to the extent that said heat wave did not last for several months in a row.

However, the further reasoning of said authors remains worth mentioning The authors, more in particular, argued that the real tragedy for the elderly residing in nursing homes was twofold.

On one hand, some elderly died gasping for breath because only few long-term nursing homes had the oxygen equipment needed to treat critically ill Covid-19 patients, pointing to the general unpreparedness of the French long-term nursing home sector to deal with an epidemic or a pandemic (and, by extension, to a similar degree of unpreparedness of nursing homes all over Europe). On the other hand, there had been a huge social drama taking place in France, as survivors, many of whom were already disoriented because of illnesses such as dementia to begin with, had been systematically deprived of family visits and close contact with their loved ones during the last phase of their lives, by measures intended to prevent the spread of the Covid-19 virus. Still, politicians belonging to French opposition parties and some nursing home directors themselves, sharply criticised Macron’s administration for its handling of the Covid-19 pandemic, including its narrow focus on hospitals, rather than on the far more vulnerable long-term nursing homes. E.g., Synerpa, a federation representing private long-term nursing homes, was quoted saying it had received “zero response” when it had written a letter to then-Health Minister Agnès Buzyn as early as 4 February 2020, with recommendations on how to tackle the pending health crisis.²²⁹

6.2.2 The United States

6.2.2.1 Covid-19 in American Long-Term Nursing Homes

6.2.2.1.1 Numbers and Cases

In the United States, according to the European Centre for Disease Prevention and Control, the first registered outbreak of Covid-19 in a nursing home occurred on 28 February 2020 in King County, Washington. According to the same source of information, by 18 March 2020, 167 contamination cases had been identified among residents, staff members and visitors of this nursing home. The hospitalisation rate for residents and staff members of this facility soon amounted to 50%, while the mortality rate among residents even amounted to 34%. Within the time frame of a few weeks only, 30 other long-term nursing homes in King County also reported outbreaks of Covid-19. From a later investigation, it appeared that staff members’ mobility between nursing facilities had contributed to this quick and wide spread of the Covid-19 virus to long-term nursing homes all over the county. The study of what had occurred in King County has, moreover, been vital for understanding the spread of Covid-19 by asymptomatic people. The diagnostic study included the testing of both asymptomatic residents and staff members, in order to be able to evaluate the spread within and between the nursing facilities. Once the occurrence of asymptomatic infection had been identified, this allowed for the implementation of facility-wide control strategies, including measures of isolating all nursing home residents, rather than just the ones showing symptoms. From this, it became clear that merely focusing interventions on symptomatic residents and staff members would not have allowed to control Covid-19 transmission in a sufficient manner, as at least half or more of the contamination cases were found to be asymptomatic.²³⁰

By 3 December 2020, at least 106,000 residents and staff members of American long-term nursing homes, besides other long-term care facilities, had died due to Covid-19. On that date, the “US Covid Tracking Project” counted a total of nearly 270,000 Covid-19-related deaths throughout the United States, which implied that nursing home residents and staff members accounted for more than 39% of all Covid-19 deaths in the country.²³¹

According to The New York Times,²³² there had at least been 179,000 deaths due to Covid-19 among residents and staff members of American nursing homes and other long-term care facilities for elderly adults by 31 March 2021. By that same date, the Covid-19 virus had contaminated more than 1,345,000 people residing in about 31,000 nursing or care facilities.²³³ While only 4% of the country’s Covid-19 contamination cases had occurred in long-term nursing or care facilities, the number of Covid-19-related deaths in said facilities amounted to approximately 33% of all Covid-19 related deaths throughout the United States.²³⁴ This is further illustrated in Table 6.5 which gives an overview of the Covid-19 cases and deaths, by 31 March 2021, in long-term nursing or care facilities of the 10 American states with the highest share of deaths linked to nursing homes.

Table 6.5 Covid-19 cases and deaths, by 31 March 2021, in long-term nursing or care facilities of the 10 states with the highest share of deaths linked to nursing homes^a

On the same date (31 March 2021), the proportion of deaths associated with long-term nursing or care facilities for the elderly at a state level appeared to be even more stark. In 9 states, the number of deceased nursing home residents and staff members was reported to account for half or more than the total deaths due to Covid-19.²³⁵

Still according to the same findings of The New York Times, Covid-19 infected people associated with nursing homes also died in larger numbers than the general population. The so-called “median mortality rate”—i.e., the number of Covid-19 related deaths divided by the number of Covid-19 contamination cases - in facilities that provided sufficiently reliable data amounted to 10%, which was significantly higher than the national mortality rate of 2%.²³⁶ There were, moreover, at least 31,000 long-term nursing or care homes which reported one or more cases of Covid-19.²³⁷

Table 6.6 lists the Covid-19 contamination cases and deaths in long-term nursing or care homes where at least 70 cases had been identified.²³⁸

Table 6.6 Cases and deaths, by facility^a

6.2.2.1.2 Causes

According to an AARP report dated 3 December 2020 and referred to by Bondy, there were several causes for the extremely high number of Covid-19 deaths in long-term nursing homes throughout the United States, such as organisational problems of for-profit homes, a lack of adequate government oversight, and a general lack of accountability in the American nursing home industry.²³⁹

A further primary cause of the high mortality rate, concerned the failure of public health authorities at all levels to prioritise long-term nursing homes in both testing and the provision of personal protective equipment (PPE), failures which left the entire sector ill-equipped to deal with the spread of Covid-19.²⁴⁰ In the opinion of Eaton, the biggest mistake in America’s response to the pandemic regarding long-term nursing homes has indeed been the country’s failure to provide nursing home residents and staff members with early and widespread access to Covid-19 virus testing material. Without adequate testing, nursing home staff initially only concentrated on isolating nursing home residents who showed symptoms of Covid-19, while asymptomatic residents and staff members could continue spreading the virus.²⁴¹

The nursing home sector itself and its lacklustre organization and working methods have also partly been held responsible. At the time of the Covid-19 outbreak, many (for-profit) nursing homes were simply understaffed and underfunded. The for-profit structure also appeared to have lowered the quality of care in many nursing homes.²⁴²

Older residents of such homes, who were more vulnerable to Covid-19 because of their age, often lived together—with many of them even sharing rooms with a roommate.²⁴³

From an August 2020 report that had been commissioned by the state of Connecticut, it appeared that for-profit nursing homes in the state had about 60 per cent more Covid-19 contamination cases and Covid-19 related deaths per licensed bed than their non-profit counterparts.²⁴⁴

The risks were reported to even have been greater in long-term nursing homes run by private equity firms, the business strategy of which consists of temporarily taking over nursing homes, rationalize their cost structure and then re-sell them at a profit. From a study by the “Americans for Financial Reform Education Fund”, it, e.g., appeared that such long-term nursing homes in the state New Jersey experienced a disproportionate number of Covid-19 related deaths.²⁴⁵

Staffing levels have also appeared of being an important factor in the spread of the Covid-19 virus. From a study of JAMA of August 2020, it, e.g., appeared that in eight states, long-term nursing homes employing more staff had fewer Covid-19 cases than facilities employing less staff members.²⁴⁶

The already quoted AARP report of 3 December 2020 also revealed that staff members in long-term nursing or care facilities who were underpaid (with an average wage of about USD 13 per hour), had to work in multiple nursing or care facilities in order to make ends meet. By doing so, they were unintentionally transmitting the Covid-19 virus over several nursing or care facilities and throughout their communities.²⁴⁷

In addition, many nursing home staff members did not enjoy health insurance or paid sick leave, which forced some to continue to work even when they had developed Covid-19 type symptoms.²⁴⁸

There were also reports about clear links between the assessed quality of nursing homes and the number of Covid-19 contamination cases and Covid-19 related deaths. E.g., researchers from the University of California, San Francisco, and the University of Rochester Medical Center, found that long-term nursing homes that had been granted a lower quality rating from their regulators before the Covid-19 pandemic, were more likely to have Covid-19 outbreaks than those with a higher rating.²⁴⁹

Another factor that has been held responsible for the huge number of Covid-19 contaminations and deaths, has been the complete lack of preparation by both the federal and state governments before the pandemic hit the United States. When Covid-19 first emerged in China in late 2019, both federal authorities and the states had failed to take any preparations against a possible outbreak in the American nursing home sector. Instead of ensuring that nursing homes had adequate protective equipment and contingency plans at their disposal, nothing had been done. As a result, when Covid-19 first hit the United States, long-term nursing homes were caught by surprise. The federal policy of prioritising critical care hospitals mandated states to purchase their own supplies. As explained before (cf. Sect. 5.3.2.3), shortly after the Covid-19 outbreak, this policy approach caused bidding wars on protective equipment (ranging from face masks to protective gowns, and even respiratory devices), leaving the long-term nursing homes empty-handed in most cases. When the federal government finally resorted to action for helping long-term nursing homes, it often did so with what has been referred to as “glaring incompetence”. E.g., during the spring of 2020, the “Federal Emergency Management Agency” (abbreviated as “FEMA”) started sending much-needed face masks, surgical gowns and other personal protective equipment to more than 15,000 long-term nursing homes throughout the United States. However, many of the shipments, which had been touted by Vice-President Mike Pence as “vital federal support” to the benefit of the long-term nursing homes, mostly contained unusable items, such as expired or defective surgical masks and surgical gowns without armholes, which were useless for protecting against the Covid-19 virus. Moreover, none of these federal shipments contained what the long-term nursing homes needed the most, namely N95 masks that would have protected staff members from inhaling the Covid-19 virus and from then contaminating the elderly residents.²⁵⁰

Another factor explaining the huge number of Covid-19 related deaths in the American long-term nursing homes has been that the federal Centers for Medicare (CMS) and Medicaid Services had decided to scale back on their regulatory oversight of nursing home facilities early in the Covid-19 pandemic, in March 2020. This decision had increased the risk factors within nursing homes even more.²⁵¹ These altered monitoring rules had been meant to prevent outsiders from bringing in the Covid-19 virus within the walls of nursing homes. But as a result, nursing homes could operate at their own discretion.²⁵²

The CMS had also provided 21 billion dollars in federal support funds to long-term nursing homes, of which USD 2.5 billion was intended for Covid-19 infection containment.²⁵³ The rest of this federal support came with “no strings attached,” according to the AARP report itself. As 70% of the long-term nursing or care homes are “for-profit” and were thus linked with higher Covid-19 related death rates,²⁵⁴ this made the AARP wonder whether said money had been put to optimal use for dealing with the crisis.²⁵⁵

6.2.2.2 The United States’ Own Aftermath

In August 2020, it was announced that, according to a “Business Insider” review of data compiled by ProPublica, the Centers for Medicare and Medicaid Services (CMS), the Paycheck Protection Program, and Medicare.gov, about 220 long-term nursing homes that had been flagged for a litany of violations, had still managed to benefit to the tune of millions of dollars from Small Business Administration Paycheck Protection Program (PPP) loans (a lending program that was part of the CARES Act; cf. Sect. 4.4.2). Together, the long-term nursing homes cited by the CMS’s Special Focus Facility (SFF) Program, as well as hospitals and business entities that own and/or manage those facilities, were said to have received between USD 149 million and USD 427 million.²⁵⁶

E.g., fifteen health citations had been levied against the Commander Nursing Center, which had been fined over USD 288,000 in the preceding 3 years, but nevertheless managed to rake in between USD 1 million and USD 2 million in PPP loans. Reports said that the residents of this nursing home had lost weight because of unmet nutritional needs and that they even been exposed to sexual abuse.²⁵⁷ Meanwhile, Kingston Healthcare Center had been cited 39 times and fined more than USD 11,600. Reports described a lack of care plans to protect residents from infections, along with leaking buildings infested with mould. Even so, Kingston was awarded between USD 1 million and USD 2 million in PPP loans.²⁵⁸ A similar situation played out at Mescalero Care Center, which had been cited 30 times and fined about USD 169,000. It nevertheless still managed to receive a PPP loan between USD 350,000 and USD 1 million. Inspectors reported inadequate dental services, physical therapy, and ulcer-prevention measures, while nurse notes indicated that surveyed residents who were receiving hospice care, were bathed only about once a week.²⁵⁹

6.3 Conclusions

A recent academic study²⁶⁰ on long-term care homes in Canada, noted that “[f]or-profit status is associated with the extent of an outbreak of Covid-19 in LTC homes and the number of resident deaths”. To quote further from the conclusion of this study:²⁶¹

We did find evidence that for-profit LTC homes have larger COVID-19 outbreaks and more deaths of residents from COVID-19 than nonprofit and municipal homes, and that this finding was mediated by the higher number of for-profit homes with outdated design standards and chain ownership. The COVID-19 pandemic has laid bare long-standing issues in how LTC homes are financed, operated and regulated. As health systems scramble to prepare LTC homes for successive waves of the COVID-19 pandemic and others search for accountability and solutions to the crisis in the sector, it is important to examine all potential explanations for observed differences in COVID-19 outcomes across LTC homes.

In the United States, alarming shortcomings of private caregiving facilities have been documented throughout the Covid-19 pandemic. In one such study referred to by the Corporate Europe Observatory, a preliminary link “between private equity ownership of nursing homes and Covid-19 related deaths” has been identified.²⁶²

Equally alarming was the case of Belgium, where an extremely high Covid-19 mortality rate has been observed in both public and private long-term nursing homes, partly attributed to bad government policy.²⁶³

In Sweden, a high proportion of temporary staff (working on zero-hour contracts, and hence not entitled to sick leave or similar social benefits) employed in multiple long-term nursing homes at once, is reported to have been co-responsible for the rapid spread of the Covid-19 virus.²⁶⁴

A wide variety of the problems confronting long-term nursing homes throughout Europe during the Covid-19 pandemic—such as no access to PPE, no replacement for sick staff members, a reliance on staff members employed by more than one nursing home…—were not exclusive to for-profit facilities. However, in the further opinion of the Corporate Europe Observatory, there were also several characteristics typical to for-profit nursing homes. The need to make 25–35% of turnover income available as profits for the shareholders, cannot be ignored when considering the ability of such private for-profit nursing homes to adequately respond to the Covid-19 pandemic. Especially problematic is the downward pressure on staff-per-resident ratios, on the number and qualification of staff members, as well as on staff members’ wages and their working conditions.²⁶⁵

Another factor that has to be considered are the supposed savings to the public purse offered by marketisation and privatisation of care and nursing services. In the context of Covid-19, this raises the question to what extent public money should still be spent to clean up the mess caused by private nursing homes during the Covid-19 pandemic. This is a question that may deserve a more detailed investigation, however, in the absence of specific empirical data, there are several warnings to take into further consideration.²⁶⁶ E.g., as early as 1986, Hawes and Philips argued that government policymakers have a clear interest in regulating the nursing home industry:²⁶⁷

• (1) First, the government has a fundamental regulatory role due to its capacity of being one of the main purchasers of formal, long-term nursing or care services.

• (2) Secondly, the regulatory system bears an important responsibility for the quality of home care, given the vulnerability of most consumers of these services. Consumers in need of long-term care, in most cases, suffer from a wide array of chronic physical, functional and/or mental illnesses or disabilities. As a result, these “consumers” have little or no influence on the decisions and behaviour of the nursing homes that admit them, implying that the government should take up a far more active role of monitoring this kind of facilities.²⁶⁸

• (3) Thirdly, most nursing home residents do not have an advocate to represent their interests, this often being the reason why they have to be admitted to a nursing home in the first place. E.g., a large proportion of nursing home residents does not have a living relative, or do not have relatives living nearby. In the United States, placement decisions on admission to nursing homes are made by social workers and hospital discharge planners. These usually have the patient’s best interests at heart, but they may operate under a system of incentives and urgencies in which finding any vacant place takes priority over truly assessing the quality of care that the nursing home provides. Even when the patient still has family members on whom they can rely, they too often suffer from the burden of finding an available place, while having no useful information at their disposal on the comparative merits of the different service providers.

• (4) Finally, the role of government in quality assurance is not only essential, but also crucial. As the Covid-19 pandemic demonstrated, substandard patient care and quality of life within long-term nursing homes remain serious problems throughout the Western world. Among the negative elements reported during the Covid-19 pandemic are: inadequate nutrition, dehydration, overdosing of medication, excessive use of physical restraints, failure to provide prescribed therapies, neglect of the psychosocial needs and ineffective government regulation, besides many other further concerns.

The key question that arises is whether nursing homes for the elderly lend themselves at all to organization by private market players. Many elements plainly argue against this, including, on the one hand, the limited financial capacity of most elderly people admitted to a nursing home, and, on the other hand, the fact that certain matters simply cannot be regarded as just another method for gross monetary gain. The elderly simply have a basic right to adequate care, and it is up to society to provide this. It is not a task that can simply be outsourced to the private corporate sector that is only interested in profit maximization for the benefit of its shareholders. Just like the hospital sector, it is therefore preferrable to leave the sector of nursing homes in the hands of government. A government which, moreover, should be strongly dissuaded from classic, neoliberal austerity policies for the running of this sector. Indeed, Covid-19 has sufficiently proven that neoliberal austerity and the outbreak of a pandemic are anything but a beneficial marriage.

In this regard, the key to running a benevolent public nursing home sector, is sufficient and reliable financial resources, which requires abandoning the current money creation model.

In our earlier books, in particular in “Towards a New International Monetary Order”,²⁶⁹ a plea has already been made for conceiving a new system of money creation, whereby, on the one hand, the power to create money would fall under government authority (instead of in the hands of the private banking system) and, on the other hand, the budgets of countries would be based on periodic allocations that ensure that each country would have enough resources to carry out a basic package of general tasks.²⁷⁰ Obviously, healthcare and care for the elderly should be part of this package, as already advocated in the aforementioned book itself.²⁷¹ In our earlier book “The tools of Law that Shape Capitalism”, some further ideas of implementing such an approach have already been worked out in more detail.²⁷²

To conclude: Monika Van Paemel, a renowned Dutch author, on March 26, 2021, made the following comment on a statement of Belgian columnist Rik Van Cauwelaert who, during a TV-broadcast, had warned that “the moment was near when we will have to accept the human damage because otherwise the economic price will become too high”. Monika Van Paemel declared to be shocked by this and said the following:²⁷³

I think of all the people who now live somewhere alone and have contributed their entire lives to our production and have raised children. We are actually the ones who stand on their shoulders. If you start to think that that category is ‘ballast’, our foundation will disappear, and the young generation will not have good prospects.