The provision of Lateral Flow tests has the potential to completely change the landscape around visits within care homes. It remains a hugely welcome addition to the toolkit of risk management that homes have to employ. It was helpful to have Susan Hopkins from Public Health England address some of the questions that have been raised around the use of LFD in relation to visitor testing in this recent blog.

The new visiting guidance outlined how testing negative using a LFD would change the way in which visits would be conducted, albeit it with a continued emphasis on the importance of wider infection prevention and control measures, and that has rightly caused very positive response from visitors and homes who are keen to get this moving.

8 days after the announcement, the guidance on how to administer this testing regime has now landed – and there will indeed be testing days ahead. Based on some of the early work with the pilots, we calculated that the additional testing regime that care homes were being asked to adopt would take up an additional 3.6 million hours of care time per month across the sector. Having read through the guidance released last night,  I suspect our estimate of the time involved was conservative, and that a time allocation of, at the very least, 30 minutes per visitor test would be more appropriate (although for many this may take up to an hour). This would increase the  additional time to carry out tests in line with the COVID Winter Plan commitment to over 5 million care hours per month – none of this has any additional funding behind it

The guidance gives more detail about the operational running of the LFD tests and it is important to go through this in detail, as the management of it will vary from home to home and is incredibly time consuming. Careful thought needs to be given to ‘where’ testing and waiting will happen. Visitors to the home, many of whom will not have had an opportunity to visit for many, many months, will be taken through a journey which starts outside the home, where they will need to be supported to don their PPE. They will then be provided with a series of bar codes with which to register their test and result. They will move into a testing area where, with support, they will need to self-administer the swab test. This will all need to be supervised, and then their swab will be taken from them and processed inside the home. Whilst this happens, they will need somewhere safe to wait which remains outside of the main home environment (ie not near communal spaces or bedrooms or residents), and can be subject to full and regular cleaning regime in between visitors. Finally, they will be told the result of the test and they will need to then register the result of their test. If this is negative, the visit can then commence but if positive they will need to take another PCR test at the home, and leave to self-isolate whilst they await their results. The visitor has the responsibility for registering the PCR test while the home has the responsibility to ensure that a courier is booked for the visitor’s PCR test. It’s complicated, lengthy and resource heavy – for all concerned.

The guidance comes accompanied by a rather extraordinary document from government which highlights a set of ‘terms and conditions’ with which it has put in place for care homes who are administering the tests.

This is in essence is telling providers that on receipt of the tests they have entered into a contract with government, under which the terms and conditions apply.  The terms and conditions stretch to 6 pages – and the balance definitely seems to be on ‘buyer beware’, the seller is leaving the room at speed! Here are the things the terms and conditions expressly state:-

• The contract starts the minute you get the tests, and everything you do from there on in is under the terms and conditions stated
• The contract appears to suggest it is with the individual home (or institution as it really unhelpfully refers to homes) yet for many the arrival point for the test will not in fact be a legal entity in their own right – therefore unable to contract in the way the T & C envisage
• The terms and conditions ‘trump’ the guidance – this is the document that must be followed (even though absolutely no consultation on these has been established)
• The guidance commits the home to a weekly meeting with the DHSC where they should share results and update (I suspect this was written for the pilot sites and has been carelessly transposed – but it is in there)
• All responsibility for testing and staffing lies with the home – including the responsibility to inform DHSC that the training has been carried out
• Only use the tests for the purposes outlined – i.e. for visitors – despite a specific focus in the winter plan that these tests should also be used on staff and residents
• Cooperate in a quality assurance programme – which is as yet unspecified
• Each party shall have to bear its own costs – surely an untenable position for the government to take against the backdrop of public commitments to the wider public that visiting would be possible – It will not be unless properly resourced

It is hard not to read these terms and conditions against a backdrop of the realities of how the ‘testing’ programme has to date been received on the ground. Over a series of months there have been repeated delays in roll out, a litany of challenges accessing allegedly prioritised portals and booking systems, drive thru testing options which sent staff hundreds of miles for tests, break down of the whole programme as the Randox shortfall hit the care home roll out programme over the summer and major delays in receiving results. Even in relation to the promised roll out of Lateral Flow Devices there have been multiple reports from providers of delayed dispatch and arrival, with the added challenge that delivery is managed through the postal system which is experiencing a wholly predictable seasonal surge!

It feels as if the evolution of the testing approach to support visiting has managed to snatch defeat from the jaws of victory. The guidance sets out a complicated and resource intensive process, which looks set to add yet more burdens to already pressurised organisations who are grappling with the extra time and resource implications of the above  – and at the same time seeking to interpret exactly what the Ts and Cs mean they are getting themselves into.  This is precious time which could have been spent planning to ensure that visitors are no longer left out in the cold.

Vic Rayner, Executive Director National Care Forum