Inside Scotland's A&E crisis: 'It's not unusual for patients to wait days for a bed'

Dr John Thomson, an emergency medicine consultant in Aberdeen and vice-president of the Royal College of Emergency Medicine (RCEM) in Scotland, said the current situation is “absolutely dire”.

He said: “In my own health board there is a patient who waited over 70 hours in the last month.

"Across Scotland, it’s not unusual for patients to wait a number of days.

“There’s patients missing medications that they’re due, or falling off trolleys and breaking hips.

"They can develop pressure sores waiting for a bed. There’s hospital-acquired infections because they’re in crowded emergency rooms.

“But we’re not good at recording harm - any harm that is being recorded will be a vast underestimate.”

Previous research found that one in every 72 patients delayed by eight or more hours in A&E dies within 30 days for reasons specifically related to that long wait - translating into 36 avoidable deaths alone for the week ending March 27.

Waiting times in A&E are the worst on record

A record 1,022 patients also spent 12 or more hours in A&E compared to an average of just 43 for the same week pre-pandemic.

Yet the number of people attending Scotland’s A&Es is nearly 1,300 lower than it was between 2015 and 2019.

For the most part, the problem has been blamed on Covid.

Officially, patients should spend no more than four hours in A&E waiting to be seen, treated, and then either discharged or 'admitted' - that is, transferred from A&E into a bed in the hospital.

However, the Omicron BA.2 variant has seen the number of patients in hospital with the virus soar to new record highs - peaking at 2,405 last weekend, equivalent to nearly one in five acute beds.

READ MORE: Over 700 staff facing axe at Scotland's flagship Covid lab

Infection controls mean that even more beds are lost as Covid positive patients - regardless of symptoms - are isolated in wards which are then closed to non-Covid admissions, and all this comes on top of physical distancing requirements which continue to squeeze number of beds in use across the NHS.

Staff sick leave has left some inpatient wards with just one nurse to 14 patients, while some hospitals are finding that the average length of patient stay has doubled compared to the pre-pandemic average - a signal of how much sicker the population has become.

3/ UK A&E performance by country, with February data for England, Scotland & Wales - https://t.co/KDrfWzIH3P pic.twitter.com/e6juBfJa9c

— George Donald (@GMDonald) April 5, 2022

Waiting times are even worse in England, Wales, and Northern Ireland, and all four UK nations have been weighing up whether the benefits of ending physical distancing in healthcare settings and twice weekly Covid testing for asymptomatic NHS staff, along with recalibrating isolation rules (perhaps based on patients’ age and vaccination status) would outweigh potential harms.

There is scepticism that it will make much difference, however.

“Long before Covid we were around 600 acute beds short nationally,” said Thomson.

“It’s gone to 1000 with what we’ve then lost from distancing and infection control requirements. What would have been a six-bedded patient room is perhaps a four-bed room now.

"But even if that capacity came back overnight, we’d still be 600 beds short.”

Dr Lailah Peel, chair of BMA Scotland's junior doctor committee and an A&E medic in Greater Glasgow and Clyde, said lengthy waits had become so common that some A&Es are running a meal service for patients.

She said: "At one point [this week] there were over 90 patients in the department. We just don't have the staffing to monitor those patients safely.

"Sometimes we're sat there with lots of patients in the department but we can't see them because we don't have any cubicle spaces, unless you start seeing them in the corridor.

"We don't have enough nursing staff to do observations on every patient as often as we'd like. We don't have enough people to do the blood tests. Every shift you go into you're fighting fires.

"It is dangerous and I have seen patients come to harm.

"I've been in tears at least once, maybe twice this week, coming home from work because it's just been awful."

READ MORE: Third of Scots cancer cases only detected after emergency hospital admission

The latest figures show virus rates, hospital admissions and Covid-related NHS absences beginning to fall in Scotland, but Peel said she fears that "end of Covid" messaging is misleading the public.

She said: "I think a lot of people think there's been this surge in cases and in a few weeks' time it'll be loads better.

"It might be a bit better, I hope it is. But I don't think it's going to be dramatically better because from my experience it's been awful since last summer.

"It's almost triggering when I speak to people and they talk about the pandemic in the past.

"Everyone who works in the NHS is very aware that the pandemic is not over; we are very much waiting to see what the next wave will bring.

"But you can't single-handedly blame Covid for everything. I've worked in the NHS now for 10 years, five of those in Scotland, and each winter has been worse and worse.

"We need more beds. We need to address social care. We need to look at employment issues: in emergency medicine we have a shortfall of consultants, we have a shortfall of senior registrars, and yet we have three junior doctors competing for every A&E training place."

Vacancy rate (whole-time equivalent) emergency medicine consultants, by health board in December 2021 and over time from 2012

As of December, 4.1% of emergency medicine consultant posts were vacant in NHS Scotland - down from a peak of 12.6% in 2013 - though in Fife and Forth Valley this was 18% and 16% respectively.

One A&E source, who spoke to the Herald on condition of anonymity, said they had seen elderly patients develop delirium - a serious and rapid decline in mental abilities, resulting in confusion - as a result of long periods delayed in bright and noisy A&E departments.

They said: "We're basically sleep-depriving old people for extended periods of time, and that's almost torture.

"The staff are suffering because they care about their patients. They're going into emergency departments day after day trying to do their best, but every day they come out feeling guilty because they know they should be doing better and they can't.

"There is no hope. People have been feeding their concerns up the line for months now and nothing is coming back down to offer a solution, or even hope."

They described the winding down of free Covid testing from Easter Monday as a "gamble" and said there was anger that more had not been done to improve air quality in hospitals, such as widespread use of Hepa filters, adding: "If we're going to burden ourselves with an extra 10-15% of capacity being used up by patients with Covid at any given time, we will never be able to achieve our elective targets and the only alternative for people is to pay for it themselves because the private sector appear to have no restrictions at all on their ability to deliver these services."

READ MORE: Mass Covid testing is about to vanish - should we be relieved or worried? 

The medic said too many beds were occupied by patients stuck on wards waiting for a care home or social care package, causing gridlock in overcrowded A&E departments and leaving ambulances stacked outside.

They said: "Ambulances can't offload [patients], and if they're stuck outside A&E, they can't respond to an emergency.

"The consequence of a social care provider failing is that you may not be able to get an ambulance for you or your loved one when you have an emergency.

"The cheapest thing to do would be to sort out social care: find out what it needs and fund it appropriately.

"An NHS bed costs £400-650 a day - that's £4000 a week. No one's paying that in a nursing home, are they?"

The latest figures, for 2019, show that the average weekly charge in Scotland was £746-a-week for a council-funded resident in an elderly care home, or £995 for a self-funded resident.

As of April 6, there were 1,679 patients delayed in hospital.

The bottleneck has been worsened by Covid, with one in three care homes closed to new admissions due to outbreaks.

However, social care providers have also struggled with staff shortages as a result of stress-related sick leave, Brexit, and workers quitting for better-paid retail jobs.

The source added: "I don’t want any more money spent on emergency care – the funding needs to go into the community. That's where you'll get most bang for your buck.

"If it was an absolute choice between 'you're not going to get any more money for the next 10 years but we're going to plough it into social care and we're going to make sure there isn't a single patient in hospital who wouldn't be better cared for in the community', I would take that in a heartbeat."

A Scottish Government spokesman said new infection control guidance had been issued to health boards in the past week which could help ease pressures on hospitals and improve patients flows.

He added: "We are still seeing high levels of Covid transmission and people in our hospitals with the virus, but there are some indications that numbers are stabilising."