Homecare Association calls for regulations requiring vaccination as a condition of deployment in CQC-regulated wider care settings to be withdrawn without delay

With only two weeks until the deadline for uptake of the first dose of COVID-19 vaccine on 3 February 2022, the government finally published the operational guidance for implementation of vaccination as a condition of deployment in CQC-regulated wider care settings on 20 January 2022. Further guidance about temporary medical exemptions has yet to appear, leaving even less time for the homecare sector to work through the complex employment and operational issues that arise, at a time of already intense service pressures. This is unacceptable.

The Homecare Association has today written to the Secretary of State for Health and Social Care, the Rt Hon Sajid Javid MP, to call for the regulations requiring vaccination as a condition of deployment (VCOD) in CQC-regulated wider care settings to be withdrawn without delay. A copy of the letter is here

We argue, with evidence, that the situation in wider society has moved on since the policy was first proposed and that the risks of the regulations greatly outweigh the alleged benefits.

From the outset, we have strongly supported vaccination against COVID-19; there is clear evidence that it helps to protect recipients from serious illness and death.

At the same time, we have consistently argued that persuasion would likely be more successful than compulsion in achieving high vaccine uptake, especially among those with genuine fears. And we have repeatedly stressed the need to balance the mitigated risk of infection with the risk of older and disabled people going without vital care.

In pressing ahead with regulations requiring vaccination as a condition of deployment in CQC-regulated wider care settings, including homecare, we believe the government has seriously misjudged this balance of risk.

We are deeply concerned that the safety and well-being of older and disabled people will be dangerously compromised by the potential loss of 15 to 20 per cent of the homecare workforce (75,000 to 100,000 careworkers, based on Skills for Care and DHSC data on workforce) as a result of these regulations. And we believe that the risk of hospitalisation and death from COVID-19 among people receiving homecare, particularly those who have been triple-vaccinated, has been over-stated and is unsupported by the evidence.

The evidence we are drawing on is summarised as follows:

1. Data from ONS and CQC indicate that, even in the first wave of COVID-19 in 2020, when supplies of PPE were patchy, routine asymptomatic testing was unavailable for homecare, and vaccines had not yet been developed, deaths of people receiving homecare were much lower than in care homes, and were similar to those in the wider population. This is largely because homecare is not typically delivered in congregate settings. ONS data show the average household size in the UK is 2.4, so the risk of transmission is much lower than in a care home with 30 to 120 residents in close proximity. Among the homecare workforce, evidence suggests that the prevalence of COVID-19 is similar to that in the wider community.
2. Official ONS data show that deaths from COVID-19 of all people at home, which include those receiving homecare, represent only 3 per cent of the total, with the remaining 97 per cent from other causes, including heart disease, dementias and some cancers. Of course, those most seriously ill from all causes may have died in hospital or hospices.
3. All older and disabled people have now been offered, and many have accepted, triple vaccination against COVID-19, which evidence clearly shows protects against serious illness and death. Data from Canada indicate that hospitalisation and death rates of triple-vaccinated people over 80 years old are lower than those of unvaccinated 12 to 29 year olds.
4. A clear distinction must be drawn, though, between the benefits of vaccination to the recipient and the alleged benefits of vaccination to others in contact with the recipient. The latter is the government’s justification for the regulations requiring vaccination as a condition of deployment (VCOD). It is claimed that if careworkers are vaccinated against COVID-19, the people they support will be safer. As outlined above, evidence suggests that people receiving homecare are not particularly unsafe in the first place, especially if they have been triple-vaccinated. It is also important to stress that vaccination is only one of a combination of infection prevention and control measures employed in homecare, including PPE and weekly routine PCR testing.
5. Evidence to justify the stated benefits of the VCOD regulations in reducing risk to others is more questionable for the following reasons:
   1. Vaccination against COVID-19 does not prevent transmission or infection to a biologically relevant extent, particularly with more recent variants. Papers in the scientific literature suggest that transmission of both the Delta variant and the Omicron variant of COVID-19 is somewhat higher in unvaccinated than vaccinated people, but vaccinated people can still spread COVID-19. And clearly, they are. In the UK, 70.4 per cent of the population are fully vaccinated against COVID-19. Despite this, we have experienced very high COVID-19 transmission and case rates. As described above, though, recipients of vaccines have a much lower risk of hospitalisation and death if infected.
   2. A requirement for boosters is not included in the regulations, though immunity from vaccines obtained at least 12 months ago is known to provide insufficient or even zero protection against COVID-19. The government has stated that this will be kept under review. It is important to note that if boosters were included in the regulations, we would currently lose 64 per cent of the homecare workforce (c. 320,000 careworkers), as only 36 per cent of homecare workers had received a third dose of vaccine by 20 January 2022.
   3. COVID-19 transmission does not depend on a person’s employment status. An individual careworker that is directly employed by a person receiving care to deliver personal care, as defined in the legislation, is exempt from these regulations. Skills for Care data indicates there are 130,000 individual careworkers operating outside the regulatory regime in England, which represents one-fifth of the total care at home workforce. In contrast, a careworker employed by a CQC-registered agency to deliver personal care is in scope. This makes little scientific sense.
   4. COVID-19 transmission does not depend on a person’s role title. A person employed or engaged by a CQC-registered agency to deliver an activity face-to-face, which is not on the list of regulated activities defined in the legislation, such as companionship or cleaning, is exempt. In contrast, a person with equivalent face-to-face contact with a client but delivering a regulated activity such as personal care is in scope. This also makes little scientific sense.
6. COVID-19 restrictions are being lifted in wider society because the government believes that risks from COVID-19 have substantially reduced. On 19 January 2022, the government announced an end to “Plan B” COVID-19 restrictions.  People will no longer be advised to work from home, face coverings will no longer be mandatory in indoor venues, and organisations will be able to choose whether to require NHS COVID Passes. Ministers have also spoken in public about the possibility of bringing forward the end of self-isolation regulations, so those who are infected with COVID-19 are free to interact with others. They have also raised the possibility of ceasing to provide free LFD test kits to the public. As the government has stated that it is time to “learn to live with COVID-19” and favours a libertarian approach to infection prevention and control, it seems inconsistent for Ministers to start implementing complex new COVID-19 regulations, when the evidence of risk and benefit does not justify this, as outlined above.

We are already seeing the serious negative impact of workforce shortages in community and home-based support and care on older and disabled people, their families, councils, the NHS and wider society.

Unmet need among people in the community and lack of ability to discharge people from hospital back home with support is paralysing the health and care system. It is leading to untold suffering as well as contributing to ambulance queues, cancelled out-patient clinics and operations, increased waiting times and a burgeoning elective backlog. This affects every citizen.

We call on the government to:

1. Recognise the high level of risk to older and disabled people of a further reduction in homecare capacity, as well as the difficulties this presents to councils and the NHS;
2. Take note of official ONS data indicating that the risk of COVID-19 to people receiving homecare is relatively low and similar to that in the wider population, and that deaths from COVID-19 of people at home represent only 3 per cent of the total deaths of people at home.
3. Acknowledge that the regulations as laid are based on questionable scientific evidence. For example, COVID-19 vaccines do not prevent or reduce transmission to a biologically relevant degree with all variants; double-vaccination 12 months ago is unlikely to protect the recipients or anyone else due to waned immunity; and it is plainly nonsense to suggest that transmission of COVID-19 is dependent on employment status or role title.
4. Accept that the situation in wider society has changed from when the regulations requiring vaccination as a condition of deployment were first proposed and withdraw them without delay before employers must start serving notice on employment contracts with vital homecare workers prior to 1 April 2022.
5. Provide funding for targeted and tailored clinical support for careworkers with genuine fears and concerns about vaccination against COVID-19, so we can encourage more to accept vaccination to protect themselves.
6. Invest adequately in homecare so we can build workforce capacity, address unmet need, reduce inequalities, extend healthy life expectancy of older and disabled people and reduce pressure on the NHS.

Homecare Association CEO, Dr Jane Townson said:

“All along, we have strongly supported vaccination against COVID-19, as there is clear evidence it helps to save lives.

At the same time, we have consistently argued that persuasion would likely be more successful than compulsion in achieving high vaccine uptake, especially among those with genuine fears. And we have repeatedly stressed the need to balance the mitigated risk of infection with the risk of older and disabled people going without vital care at home.

In pressing ahead with regulations requiring vaccination as a condition of deployment in CQC-regulated wider care settings, including homecare, we believe the government has seriously misjudged this balance of risk.

Why would we choose to dismiss up to one-fifth of the homecare workforce – 75,000 to 100,000 careworkers - when there is already severely inadequate homecare capacity to meet demand? We fear for the safety and well-being of older and disabled people when they are unable to access vital support from careworkers to enable them to live well at home. Who will care for them? Neither central nor local government have responded to our repeated questions about their contingency plans. The government’s course of action seems particularly reckless when there is no evidence of high death rates from COVID-19 in people’s own homes, including among those receiving homecare, and the scientific basis for justifying the regulations is highly questionable.

Councils are unable to source homecare to meet need and NHS trusts are struggling to discharge people from hospital. This is contributing to ambulance queues, cancelled outpatient appointments and operations, an increase in waiting lists and difficulty in addressing the elective backlog. This increases the risk of avoidable harm to anyone in society who may need medical attention.

Last week the government announced that “Plan B” restrictions are being lifted in wider society because they judge the risks from COVID-19 to have decreased. It’s inconsistent for the government to claim, on the one hand, that the end of the pandemic is in sight, whilst on the other introducing onerous new regulations that heighten risk to older and disabled people, and wider society, without delivering obvious benefits.

We call on the government to withdraw the VCOD regulations in CQC-regulated wider care settings without delay.”