**1. Introduction**

COVID-19 pandemic has affected people's daily life dramatically since December 2019, since it was firstly discovered in Wuhan, China, in December 2019. The pandemic has already spread out to the entire world since March 2020. More than 211 million cases and 4.42 million deaths have been reported and confirmed all over the world. The COVID-19 pandemic has already become one of the deadliest pandemics in human history.

Globally, residents in long-term facilities have experienced disproportionately high morbidity and mortality from COVID-19. Across Europe, almost all countries have struggled to protect vulnerable people in long-term care facilities, no matter their relaxed or strict strategies. Despite the difficulties arising from differences in definitions, in almost all countries where there have been deaths linked to COVID-19, a substantial proportion of those deaths were among care home residents [1]. Based on the same report from International Long Term Care Policy Network, the current average of the share of all COVID-19 deaths that were care home residents is 46% (data from 21 countries). Take an example of May 2020, in Belgium, 51% of the country's 9,052 fatal COVID-19 cases were reported from long-term care facilities [2]; there were 7,469 reported cases from long-term care facilities in France, including 66% from nursing homes and 34% from other facilities [3]; Germany had reported 22,071 infections related to institutions caring for the elderly (long-term care facilities and nursing homes), disabled people, homeless people, migrants, or those in prison [4]. In the US, COVID-19 also has been shown to affect the elderly (aged 65 years and older particularly severely, with this demographic having the highest COVID-19-associated hospitalization rate around 600 per 100,000 cases based on the date in 2020 [5].

Given that older adults experience a greater number and severity of chronic diseases and disabilities, it is inevitable that COVID-19 will disproportionately affect this population [6]. Thus, it is not surprising that elderly people residing in long-term care facilities, such as nursing homes, care homes, have the greatest susceptibility to COVID-19, as well as the poorest outcomes from infections. This Chapter would like to overview the insight and impact of COVID-19 on the care homes in the UK, US, and Australia, and provide possible implications for the longterm care market post-pandemic.

### **2. The care homes in the United Kingdom**

#### **2.1 COVID-19 in care homes**

The UK government publishes daily statistics on COVID-19 related cases and deaths. The detailed reports about care homes across the UK were published in different ways in each separate sub-section.

In England, the Office of National Statistics (ONS) started publishing data on all care home resident deaths on April 11th, 2020.29,511 care home residents in England died from COVID-19 or related causes up until July 23rd, 2021, which is 22% of all England COVID-related deaths. The lower percentage of deaths in 2021, compared with 2020, also relatively shows the effectiveness of the vaccines.

In Scotland, the Care Inspectorate Scotland (CIS) has reported weekly data on confirmed COVID-19 related death of care home residents since May 25th, 2020. There are 10,505 COVID-19 related deaths in Scotland overall as the date of August 16th, 2021, 3,317 care home deaths (32%) are included. However, even there's a lower number of deaths in Scotland, the percentage of COVID-related nursing home deaths in 2021 is higher than that in 2020. The elderlies living in care homes (nursing homes) are still the group that has been hit the most.

In Wales, Care inspectorate Wales (CIW) reported weekly data on notifications of deaths of care home residents. A total of 1,932 care home residents' COVID-19 related deaths have been reported to the CIW, since the first confirmation on March 16th, 2020. There are 24% of overall COVID-related deaths in Wales happened in care homes (nursing homes).

The Department of Health of Northern Ireland released daily statistics on COVID-19 cases and deaths since April 19th, 2020. By the date of August 26th, 2021, there are 2,337 COVID-19 related deaths in Northern Ireland. Of those, 439 occurred in residential/care homes, and 1,859 were confirmed in hospitals [7]. During Fall 2020, 437 care home residents died from suspected or confirmed COVID-19, i.e., around 81% of all COVID-19 care home resident deaths occurred within the care home [8]. Therefore, the total care home resident deaths make up 14% of all COVID-19 deaths in Northern Ireland (**Table 1**).

#### **2.2 The structure of the care homes in UK**

The UK care home market is a relatively fragmented sector. The structures of care homes are from large corporate operators providing in excess of 10,000 beds to sole traders with one or two homes. Most of the care homes are operated by charities *Challenges and Futures of Long-Term Care Industry after COVID-19 Pandemic DOI: http://dx.doi.org/10.5772/intechopen.104316*


*Source: Office of National Statistics; Care Inspectorate Scotland; Care Inspectorate Wales; Department of Health of Northern Ireland.*

#### **Table 1.**

*The COVID-19 statistics about care homes in the UK (July 2021).*

and other not-for-profit organizations. The care home industry, as a whole, is a vital social service. The independent (non-public sector) operators, such as the 10 largest for-profit providers, dominated a quarter of the market. Smaller groups made up around 38% of capacity, with the remainder owned by operators with one or two homes [9]. According to the Grant Thornton report in 2018, in recent years, a two-tier market has emerged based on payment methods, including public pay and self-paying. The operators whose income is mainly from public supports, such as local authority or NHS usually achieves significantly lower profits than those with self-paying.

Like many other countries, the UK's age structure is shifting towards older ages. In 1999, around 15.8% of people were 65 years and over, this increased to 18.5% people in 2019 and is projected to reach around 23.9% people by 2039 (**Figure 1**) [10].

The increasing number and percentage of an aging population will be a large group requiring access to care services, such as residential care, care home services, and nursing homes. However, although the growth rate in the 65+ population is forecast to accelerate over the next decade, the absolute number of long-term residential accommodations has declined by 4.4% between 2001 and 2016 [9]. In 2017, 14.8% (estimated) of 85 years and older were in elderly residential accommodation, compared with 25.2% [9].

There are two types of payments for elderlies, one is from local authorities (i.e., public payment), the other one is self-pay. According to Grant Thornton's research in 2018, around 25% of care homes have over 75% of residents placed by local authorities. Average fees covered by local authorities were 10% less than the total cost of providing care, approximately a 200 million pounds to 300 million pounds shortfall in funding. To counteract this, self-funders have to pay around 40% more out of pocket to care homes, compared with the UK council-funded patients. Even though, the self-pay market is still growing at a fast rate.

#### **2.3 The challenge of the care homes in UK**

The biggest challenges of care homes in the UK, before the COVID-19 pandemic, are three aspects: decreasing potential demand due to the switching payment methods; increasing population size with limited bed numbers; declining qualified staff and nurses in care homes. These challenges, under the outbreak of COVID-19, become much tougher and more difficult to deal with.

**Figure 1.**

*Percentage of Population by Age Group in the UK. Source: Office for National Statistics (January 2021).*

Before the COVID-19 pandemic, the potential demand for care homes have already decreased due to the switching payment methods. Self-funders become the new focus of the market after several care home closures that focused on local authority-funded payers [9]. Without the support from the local authority, not every single elderly, who is eligible for residential care homes, has sufficient ability to self-support his/her stay and other further expenses. After the pandemic, due to the high numbers of confirmed cases and deaths, a proportion of potential consumers would start to question care homes and reconsider their options after retirement. The demand for care homes may have an even sharp decline during the post-pandemic period.

The residential care home industry has experienced dramatic changes due to the pandemic. With the drastic hit from COVID-19, residential care homes would have to face many potential problems, such as social distancing bed arrangement, more inputs on disinfection supplies, etc. The capacity of the care homes dropped because of the limitation of room and space, to protect patients and follow the pandemic safety rule. Piling inputs on disinfection supplies may cause declining investment in other aspects (such as staffing, daily operation supplies, etc.), which possibly affect the daily routine or even the operation model. The percentage of net earnings1 among care home providers falls from 32.8% in 2006/07 to 25.2% in 2016/17, which has been attributed to increased food and property costs, the freezing of local authority fee rates in real terms, and higher wage costs before COVID-19 [9]. After the pandemic, the care homes may face an even lower percentage of net earnings due to the increasing investment in preventive and disinfection supplies and higher hiring costs for qualified staff.

Hiring a qualified and satisfying staff was one of the biggest challenges for the care homes in the UK before the pandemic. It is estimated that 1.22 million social care workers will be needed between 2016 and 2036 [9]. The increase of national living wage (NLW) and national minimum wage (NMW) has raised the real wages and the original costs of each care home. However, the pandemic completely changed the story of nursing education, which may turn the staffing situation in UK in a different direction. According to the data from the Universities and Colleges Admission Services (UCAS), there has been a total 37,635 nursing students accepted onto the course in 2020, comparing 30,395 in 2019. It includes 29,740 students placed in England, 4,785 in Scotland, 1,985 in Wales, and 1,125 in Northern Ireland. There was a significant fall in nursing students in England in 2017 due to the

<sup>1</sup> Net earnings mean the earnings before interest, tax, depreciation, amortization, rent, and central management costs.

removal of the NHS bursary. This 2020 number shows a new faith and understanding of the nursing world during pandemic. Even though, the Health Foundation warned the government's pledge for 50,000 more nurses by 2025 would be insufficient to meet growing demand, especially during the coronavirus pandemic. The pandemic may still have potential to shrink this gap by encouraging more people to pursue careers in medical field.
