In hospitals, waiting lists have become so long that people have to queue for over two days to be seen. Patients are advised to avoid turning up if they can help it. Bed shortages mean people spend nights on corridor floors. Over 30 patients markedly deteriorate or even die each week as a result of delays. You could be forgiven for thinking this dire situation is unfolding in a developing country, perhaps without proper health infrastructure. It’s not: this is happening all across Scotland.
Since the pandemic, A&Es in Scotland have gone from bad to worse. Extreme wait times have increased tenfold: over 4,000 people spent more than 24 hours waiting in emergency departments over the last year. Almost 250 patients had to wait more than two full days.
Patients are following the advice of health boards – and staying away. Almost half of Scottish adults said they had avoided using NHS services when they felt unwell or needed treatment. Even then, hospital wards are still filling up beyond capacity, with their occupancy ‘above 100% at times’ as Dr Caroline Whitworth, acute medical director at the Edinburgh Royal Infirmary, reported on BBC Radio Scotland this morning. In Glasgow’s Queen Elizabeth University Hospital, on one night alone 48 patients were forced to sleep in corridors and on trolleys.
Public Health Scotland published the latest figures for A&E waiting times last week. Comparing them with the situation five years ago beggars belief. In 2017 in NHS Forth Valley, which caters to the Falkirk and Stirling areas, 19 patients had to wait more than eight hours. No single person had to wait more than 12. During the same week this year, with similar numbers of patients passing through the hospital doors, just under 300 patients had to wait more than eight hours to be seen in A&E; 127 were left for longer than half a day. While Forth Valley was found to be the worst performing A&E in terms of wait times, the situation there is not an isolated problem. In Aberdeen NHS Grampian saw a seven-fold increase in the number of patients waiting for more than four hours to be seen; just outside Glasgow, NHS Lanarkshire only managed to see half of its emergency patients on time.
If finding space for patients in hospitals is becoming harder, it’s also difficult to get patients out. Staff from Edinburgh’s Royal Infirmary estimate that approximately one in six of their beds are taken up by patients fit for discharge but who can’t leave without adequate social care arrangements – which they aren’t getting.
A doctor from one of Glasgow’s largest hospitals told me the situation is the same there: ‘If patients lack family support or financial security then it can be impossible for them to get the care they need in the community. The high volume of patients needing social care, combined with staff shortages in the care sector, result in this mounting pressure. I know people who have been on the wards for years who do not need inpatient treatment, taking up vital bed spaces.’
Bed-blocking in hospitals won’t improve unless the NHS and social care sector can reverse their staffing crises.
Jillian Evans, head of health intelligence in NHS Grampian, pointed towards failings in the community social care on BBC Scotland’s Sunday Show. ‘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,’ she said. ‘The waiting times are a symptom of what’s happening across the healthcare system,’ she added, describing the system as being ‘very bunged up’.
Don’t forget that all this has been happening in September and October before the winter months have even begun to take their toll. If nothing changes, then the worst is yet to come. Autumn last year was the 'deadliest on record' in Scotland. Last winter saw the total number of deaths in Scotland reach the third highest level since the century began. This winter, there are concerns that a ‘twindemic’ of Covid plus a severe strain of flu may further weaken the capacity of the health service – and now the bed shortages pose another serious threat to healthcare in Scotland.
What are the Scottish government doing to alleviate the stress on the NHS? Humza Yousaf – recently dubbed by Scottish Labour as ‘Scotland’s worst health secretary since devolution’ – painted a bleak picture. He admitted that ‘the NHS is not performing at the level that any of us would like’ and that the SNP’s recovery plan for the service will take at least five years. He implored people to understand why the NHS being under such significant pressure, but his reasoning – a ‘triple whammy’ of Brexit, the pandemic, and high inflation costs – was aimed at shielding politicians from the blame. Westminster came under fire, unsurprisingly. Yousaf urged ‘the UK government to undo the damage they’ve done’. Was the Scottish government going to shoulder any responsibility? ‘We’ve got to live in the reality of the finite budget the Scottish government has access to,’ he replied.
How does NHS Scotland compare to England’s services? The Scottish government often notes that Scotland’s emergency departments are outperforming England’s on the target for patients to be seen within four hours – but senior medics have poured cold water on this positive comparison. Statistics from Public Health Scotland only refer to 30 of the 91 A&Es in Scotland. These 30 are the larger departments that generally provide a 24-hour consultant led service, but the variation between them is enormous. The busiest department sees over 2,000 weekly attendances, while others included in the figures are remote and therefore see less patients, around 100 per week. The Scottish government measures the performance of these units against 170 of England’s type 1 ‘major’ A&Es that deal with the most severe situations, including major trauma cases involving, for example, shootings, stabbings or extreme road traffic accidents. Dr Neil Nichol, a retired emergency medicine consultant, explained: ‘None of these are comparable sites to those in England. Neither Perth Royal Infirmary not Inverclyde Hospital take major trauma so, again, are not comparable.’
Nicola Sturgeon told MSPs a little over a month ago that Scotland was performing better than England on the four-hour target in July. But if all A&E services are taken into account (rather than just England’s busiest type 1 departments), then England outperformed Scotland. In England, 71 per cent of patients are seen within this time frame, compared to 69.9 per cent north of the border. In August, the gap widened: England saw 71.4 per cent of patients were dealt with within four hours, to 69.7 per cent in Scotland.
It's easy to pass the blame. But bed-blocking in hospitals won’t improve unless the NHS and social care sector can reverse their staffing crises. Job retention levels are at record lows: one in nine Scottish nurses quit the profession last year. Too many places on nursing courses are left unfilled. BMA Scotland chair, Dr Iain Kennedy, said of staff satisfaction: ‘It would be reasonable to say that staff morale within our NHS in Scotland is possibly at the lowest level it has ever been. There is simply not enough staff to meet demand and the pressures of ever-increasing workloads is having a detrimental effect on the wellbeing of the workforce.’
Seven per cent of medics are leaving the profession within their first three years of qualifying and levels of discontent amongst junior doctors regarding working conditions are rising, as I wrote about earlier this year. Dr Kennedy agreed: ‘Poor workplace culture and unacceptable pay awards are driving staff to consider their options outside of the NHS. The government must act fast to not only recruit more staff to the workforce, but crucially put measures in place to retain the valuable workers we already have.’
There is a growing appetite for industrial action among NHS staff at all levels. This is already playing out in England, where junior doctors have voted to ballot for industrial action in January 2023. This discontent is mirrored in the care sector, nursing homes are struggling to recruit carers. As a result, many care homes in Scotland have had to close their doors.
The capacity crisis is simply another branch of the workforce one. If hospitals were given more bed space, they would need more staff to man them. Care homes could take more patients if they had more staff to work in them. The truth is that the healthcare sector is no longer an attractive place to work. Patient demand is increasing at the same time as the supply of staff is approaching an all-time low. Employees are unhappy with their job conditions and are fast realising they can work less hours for more money and a better culture elsewhere. Politicians need to stop their blame games and one-uppery if they want to return the health service to its feet – and dignity to patients – fast.
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