The NHS in Scotland is under enormous strain. Three health boards north of the border have stopped non-urgent elective care as the crisis worsens. Urgent treatment and cancer care is being prioritised as patient demand continues to rise past unmanageable levels. The last time we saw this happening was during the pandemic. What’s going so wrong?
One of the major issues in Scottish hospitals is bed-blocking: wards are full of patients who can’t be discharged. This means there is no room for those who turn up to A&E requiring overnight admission.
The shocking part, though, is that many of those patients stuck in hospitals don’t need to be there. On average, there are 1,950 delayed discharges in Scottish hospitals each day. The number of people medically fit for discharge (which is a little different than being ‘medically fit’) is increasing. So, too, is the number of patients waiting over 12 hours in emergency departments.
These patients, fit for discharge but confined to hospital beds, remain on the wards not because there are issues with hospital transport or finding staff to help move them, but because the social care in Scotland is grinding to a halt. Claire Burden, chief executive of NHS Ayrshire & Arran, one of the health boards stopping elective treatment, told staff: ‘These pressures are also being faced in our social care services across East, North and South Ayrshire. In particular, Care at Home services in the three health and social care partnerships are being particularly affected by increases in demand, as well as workforce challenges.’
And it’s true: Scotland’s hospitals are at occupancy levels of 95 per cent as of last Wednesday. A number of junior doctors in Scotland told me about how their wards were filling up, and many patients, who were no longer requiring hospital treatment, were unable to leave.
‘Half my ward is medically fit, with patients just needing a package of care,’ one told me. Another medic, working in a surgical ward, described their current situation after they had been told about elective operations being paused:
‘They’ve stopped all elective theatre to free up beds,’ they said. ‘People are now coming into hospital extremely unwell, they’re getting put under "medicine" but being boarded (given a bed) on surgical wards.’
Only a few months ago, Jillian Evans, head of health intelligence in NHS Grampian warned about the dire state of the care sector:
‘We know that there is such an increase, the highest levels we’ve seen in years, of patients who are clinically fit to be discharged because of the shortages of social care staff in the community, or in care homes.’
Her words have come to pass. The governments in both Scotland and England are trying to buy up beds in care homes so that this congestion can start to ease. Health Secretary Steve Barclay said this week that up to £250 million would be spent on speeding up the process of discharging people from hospital. In Scotland, Nicola Sturgeon announced that ‘immediate extra funding’ will be given to health boards so that they can buy beds in care homes to help accelerate patient discharge from hospital.
Neither of these offer a simple fix. I spoke to a care home manager in Scotland who told me that while their workplace was being contacted by the local council and offered significantly more than the asking price for beds (approximately £1,100 vs the normal rate of £832), they simply didn’t have any extra capacity. The home is full and there is already a waiting list.
For those care homes with spare beds, there are also questions surrounding whether staff will have a say in which patients they accept from hospital. Certain patients can be more challenging to manage than others, depending on their condition, and local care homes may not have the staff, or the right kind of staff (nurses, as opposed to care workers), to handle the influx. One care worker told me about how the pressure on the sector is spilling over from the health service. As local councils have bought up beds for patients coming from hospital, patients in the community were finding it much harder to get a bed in a local care home.
The care sector is already under pressure: carers are leaving the industry due to dissatisfaction with their working conditions and pay. Another carer told me about how there is a growing problem with at-home care, which allows people to remain in their own homes. Staff often have to travel a long way to get to patients’ houses, and many are finding that the high cost of fuel is becoming unaffordable, particularly when expenses often don’t cover the actual fuel prices.
While Evans described the hospital system as ‘bunged up’, Burden describes it as ‘congested’: there’s currently no room for movement while the care sector remains in disarray.
England has seen its social care workforce significantly decline; the country is projected to require almost half-a-million more staff by the middle of the next decade, but the industry lost 50,000 workers last year, leaving approximately 165,000 vacancies. The outlook for Scotland’s care workforce is a little less bleak: the workforce has decreased by 0.6 per cent since 2020, with a stability index of 75.5 per cent (meaning that around three-quarters of the workforce stayed in the same post since last year). But there is a staffing crisis, as Donald Macaskill, chief executive of Scottish Care, told the BBC in November. He warned that 40 per cent of the country’s 800 private care homes could close in the face of rising energy costs and a staff shortage.
And as care homes struggle to make space for patients needing to leave hospital, the NHS is struggling to find beds for those new patients needing admitted each day. On Tuesday, an email was sent out to staff from Claire Burden, of NHS Ayrshire & Arran, which announced that elective procedures and routine appointments would be paused. ‘We are pausing routine inpatient elective surgery for a period of three weeks from Monday 9 January 2023,’ the email read. ‘We continue to focus on the decongestion of our acute and community hospitals, which will help us relieve the pressure in our Emergency Departments and Combined Assessment Units… We have opened all additional beds where possible, and are seeking alternative pathways for those patients who do not require their care to be delivered in an acute hospital setting.’
The health board extended this change to general practices in the area, with Burden writing that ‘due to the overwhelming demand across general practice, we are asking GP practices to move to only seeing urgent and emergency care patients’.
Both NHS Borders and NHS Greater Glasgow & Clyde (the latter Scotland’s largest health board) have told their staff similar, having also temporarily paused elective procedures to prioritise urgent cases. This means that any patient expecting to attend a routine operation during this three week period will have their slot rescheduled. Unaffected patients include children, those who require urgent treatment, or patients who can be operated on as a ‘day case’, meaning they won’t require a hospital bed. NHS Greater Glasgow & Clyde offered an apology to any patients affected by this alarming move, promising it would ‘make every possible effort to offer them an alternative date at the first opportunity’.
Bed-blocking in Scottish hospitals is out of control. Patients who need treatment can't get the help they need. But the ‘solution’, of buying up care home beds in an attempt to empty hospitals, affects those patients in the community who also need access to care. It feels rather like trying to fix a gaping wound with a cheap plaster. Until the staffing problems in both the NHS and the care sector can be fixed, and until more physical space with adequate staffing levels can be made available (as opposed to repurposing existing beds), this capacity crisis will be going nowhere.
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