NHS winter crisis is about staffing, not Covid, say clinicians

In a statement on Friday, announcing its move to 'Black' - the highest risk status - deputy chief executive Laura Ace said all three of the region's acute hospitals had reached "critical occupancy" with A&E departments "overwhelmed by the number patients attending and needing admitted".

Family members have been asked to step in and help care for relatives at home so that they can be discharged more quickly.

After a dramatic fall during 2020, A&E attendances in Scotland are now similar to pre-pandemic levels but hospitals have fewer beds available; fewer than 65% of people attending Lanarkshire A&Es in the week to Oct 10 were treated and then admitted or discharged within four hours

It came days after figures revealed that an unprecedented 612 people had spent more than 12 hours in A&E departments at the start of October waiting for a hospital bed.

Delays like this are more than just an inconvenience; the 'Getting It Right First Time' report produced for NHS England in 2017 found that one in every 67 patients who spend 12 or more hours in A&E will die as a direct result.

READ MORE: Hospitals 'jammed' amid signs pandemic backlog starting to hit NHS

"We can't deny that harm is occurring to patients," said John Thomson, vice-president in Scotland for the Royal College of Emergency Medicine.

"It's a poor, poor patient experience, and it's outwith our control - there is no way for us in the emergency department to impact on the exit block.

"But what it is doing is significantly impacting on our ability to safely manage the new patients who are turning up."

John Thomson (inset), vice president in Scotland for the RCEM, said lengthy A&E waits due to hospital bed shortages would inevitably lead to an increase in avoidable deaths

Dan Beckett, Scottish representative for the Society for Acute Medicine, said the outlook feels "bleak".

He said: "We're worried where things are going to go in the run up to Christmas, and at the typical peak demand time of early January. Our members are very concerned about how that is going to play out and the impact on patients who are going to need to access urgent and emergency care.

"Options are very limited. There's elective work that can be cancelled and then beyond that there's urgent elective work, cancer work - which of course we're loathe to cancel and boards really don't do that unless they're absolutely pushed - but beyond that there is really little else that can be done."

The root of the crisis, according to clinicians on the frontline, is two-fold: beds, and staffing.

The RCEM estimates that Scotland's NHS is 1000 beds short for demand: a combination of a 600-bed shortfall pre-pandemic, and a further 400 lost through physical distancing rules.

READ MORE: NHS Recovery plan will fail without serious investment in staffing

Even before Covid, A&E attendances were rising year-on-year and a steady 30% of these patients were requiring admission- yet at the same time, the actual number of acute beds was shrinking in line with the Government's vision that more people should be looked after the the community.

Now, with A&E attendances and admissions back at pre-pandemic levels, but even fewer beds than before available, the bottlenecks are worse than ever.

At the same time, a recruitment and retention crisis in social care is driving both a rise in avoidable hospital admissions and bed blocking.

As of October 20, nearly 1,600 hospital beds in Scotland were being lost to delayed discharge.

Donald Macaskill, chief executive of Scottish Care said care homes were paying 'exorbitant' rates to agency workers just to remain open (Image: Newsquest)

Donald Macaskill, chief executive of Scottish Care, the umbrella body for private providers, said: "The whole point of social care is to to keep people out of hospital, but in some parts of Scotland the shortages are so bad that GPs and community nurses are basically doing the job of home care - and if they can't, people are admitted unnecessarily into hospital.

"Then, at the other side, when patients are well enough to leave, you have that pressure on discharge because if providers can't deliver care, the patient can't go back to their own home or into a care home."

Beds lost to delayed discharge, from March 4 2020 to October 20 2021 (Source: Scottish Government)

In some cases medics told the Herald on Sunday that fully-vaccinated elderly patients who recovered within one or two days of being admitted to hospital with Covid were routinely finding themselves stranded on wards because their home care package had been reallocated, sending them back to the bottom of the waiting list.

Macaskill said 28% of care home managers in Edinburgh alone had quit in the past nine months and 80% of care homes and home care services are struggling to fill vacancies due to a combination of Brexit-related immigration policies, sickness absences exacerbated by the stress and mental distress of the pandemic, and an exodus of staff to better-paid jobs in retail and hospitality.

READ MORE: Face-to-face hospital appointments cut to 'reduce road traffic' during COP26 

The workforce crisis comes at a time when care homes require more staff than they did pre-pandemic - to manage everything from infection control to enhanced visiting - and pushes premises ever closer to missing the vital safe staffing thresholds required by regulators.

"There are care homes in Scotland who are struggling to survive and who are using agency staff at exorbitant rates just to remain open," said Macaskill.

"That's not sustainable long-term."

In hospitals, meanwhile, there is a sense that the pandemic has both exacerbated and exposed an existing crisis.

"Everyone could see the workforce was ageing, that there was a bubble of people in their 50s who were all going to fall off the end of their career roughly now - but this has precipitated people leaving," said Graeme Eunson, chair of the BMA's Scottish consultants' committee, adding that it expects to see a "huge number" of retirements in 2022.

In addition, he fears that the reopening of borders in New Zealand and Australia, where clinicians' pay and work-life balance is significantly better than the UK, will trigger an "exodus of staff" - especially younger doctors.

The increase in consultants in Scotland has not kept pace with demand. Vacancy rates for doctors, nurses, midwives and allied health professionals have all increased since 2011 and by September 2020 55% of consultant vacancies subject to recruitment efforts had been empty for at least six months

Even before the pandemic, consultants UK-wide were retiring early or cutting their hours due to a bizarre pensions tax loophole - still largely unresolved - which meant they were actually losing money for working overtime.

But for Eunson, a paediatrician in the Scottish Borders, the bottom line is that actual consultant vacancies have been "grossly underestimated" for years because official figures only include posts which health boards are actively trying to fill.

"Ultimately, the workforce planning has not produced enough people coming in at the bottom to meet the numbers falling off the top," said Eunson.

Graeme Eunson, chair of the BMA's Scottish consultants' committee

Mike Griffin, president of the Royal College of Surgeons Edinburgh, said the Scottish Government's plans to create a network of diagnostic and elective surgical hubs to help clear the backlog was welcome, but could have no immediate impact.

"You have to build them first, then you have to staff them - and at the moment there are no staff," said Griffin, who said the focus now should be on persuading recently retired medical and nursing staff to temporarily return.

"Ever since the vaccination programme got going we've touted the recovery programme, but realistically it's not going to kick in until Spring next year. It's just not going to happen.

"We have to concentrate right now on retaining our staff, getting others to return, and on making sure that the emergency service functions and the very urgent, high risk stuff continues to be done.

"If we do that we will be able to help ourselves over this very difficult winter period."

READ MORE: Retired NHS medics put off NHS return by 'complex' process and 'inappropriate' job offers 

In intensive care, a snapshot survey by the Scottish Intensive Care Society Audit Group (SICSAG) in September highlighted that 60% of ICUs were relying on bank, agency and redeployed nurses to meet the required nurse-to-patient ratios, and that one in five were breaching guidelines which stipulate that no more than 20% of nurses covering any one shift should be drawn from the staff bank or agencies.

"In the first wave, other areas of the hospital stopped so we had a huge number of staff available to come and work in ICU," said Naz Lone, SICSAG chair.

"Now, because we're maintaining a reasonable amount of other activity, those staff aren't available.

"So even when we have an empty bed which we should be able to admit someone to, there just aren't the staff."

At the peak of the third Covid wave Scotland's ICUs were admitting 12 patients per day, compared to a peak of 23 in wave one and 16 in wave two

Cancelling planned surgeries typically frees up around 20% of ICU beds, said Lone, but even during the most recent wave - with a highly vaccinated population - two in every five beds were occupied by Covid patients.

Over 80s accounted for 25% of Covid hospital admissions in the most recent week (Source: Public Health Scotland)

Lone and colleagues hope that, should Covid rebound - potentially with a resurgence of flu on top - boosters will cushion ICUs from disaster.

He said: "We know that there's a failure rate of about one in 10 for the vaccines, so when you end up with such phenomenally high circulation of the virus in the community - even though it appears to be lots of younger people infected - that filters through and eventually reaches those unlucky one in 10.

"We were seeing more people with immunosuppression coming in, or the unvaccinated minority- they have always been overrepresented in our ICU groups.

"That's why we're hoping that having boosters going into winter, compared to this past wave, could be the thing that helps to break the link between the big peaks in the community and what we're seeing in ICU.

"Given how difficult these problems are to solve, I also think it's important to ask what we - the public - can do, and that comes back to making sure as many people eligible for flu vaccinations and boosters as possible get them.

"There are also still people who haven't had first doses - can we persuade that final percentage of the population to get it? Because it really is as simple as, if we end up with more Covid coming in, then other parts of the health system have to stop."