Scotland's swamped A&Es 'wouldn't cope' with a terror attack

The run-up to Christmas saw a record 1,925 patients spend over 12 hours in emergency departments (EDs) with handover times for ambulances also deteriorating.

In the week from Boxing Day, one in 10 patients arriving at hospitals in Scotland by ambulance waited over three hours to be offloaded into A&E.

Some patients are understood to have died while waiting in the back of ambulances.

Bed shortages in hospital have been exacerbated by spikes in Covid and flu admissions during December.

Wards accommodating patients with infectious respiratory illnesses have to be closed off to other patients, squeezing capacity at a time when around one in eight NHS beds is already occupied by patients who are medically ready to leave but stuck in hospital due to a lack of social care.

Flu rates in December were the highest for 12 winters in Scotland, with hospitalisations also exceeding 2017/18 levels - the most recent bad winter flu season. One in 25 also had Covid by the end of December, the highest levels since summer (Image: PHS)

Dr Lailah Peel, a Glasgow-based junior doctor in emergency medicine and deputy chair of BMA Scotland, said she was seeing previously resilient consultant colleagues "falling apart" under the strain.

She said: "I hate to think what would happen if we had a major emergency - like a terrorist incident or a major crash - we just wouldn't be able to cope.

"What's depressing is that I've been talking about the crisis in our A&E departments since January last year when we had Omicron - but what's changed? It's hard to see that nothing could have been done in the past 12 months."

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Senior clinicians at several major sites, including the Queen Elizabeth University Hospital, have urged NHS bosses to declare a Covid-style major incident in order to maximise frontline resources, but this has so far been resisted.

"If we can't escalate to a major incident now, then when can we?," said Peel.

"It's scary. How many more patients have to die before that can happen?"

Peel said the week before Christmas was the first time she had seen so-called "standby" emergency admissions - who would normally be rushed straight to resuscitation bays - treated in the corridor.

These are patients who are blue-lighted to A&E, with ambulance crews calling ahead so that ED teams can be ready to receive them.

"It's horrific that it's got to that, but we just didn't have any capacity," said Peel.

"There's also a real pressure to discharge people at the moment, and the danger is that I don't think it's always being done safely.

"Some people are discharged home and we see them back in A&E the next day and they're really not okay.

"That's not widespread - but it's happening."

By October - the most recent month for which data is available - a record 1,898 people each day were stranded in hospital each day due to delayed discharge. On average, these patients occupied beds for 23 days longer than necessary (Image: PHS)

The Royal College of Emergency Medicine (RCEM) has estimated that - even pre-pandemic - Scotland's NHS was around 1000 beds short of what it needs.

UK-wide, the RCEM warned that the current logjam blighting A&E's is costing around 300 to 500 lives a week.

Dr John-Paul Loughrey, vice-president for Scotland at the RCEM, said: "Most doctors and nurses in emergency departments can readily identify cases in their own department where there has been patient harm - whether that's the 90-year-old patient who spent six hours on an ambulance stretcher and is moved into ED hypothermic and in pain, or the increased rates of people leaving without ever being seen.

"There's a risk associated with that as well."

READ MORE: Patients 'died in ambulances' last week amid 'horrific' handover delays at A&E

The QEUH in Glasgow recently adopted a 'continuous flow' model - a push to get patients out of the ED and into wards even if no beds are available. A similar system is already used in Tayside.

The goal is to reduce ambulance handover times and A&E delays, but some nurses warned that adding "trolley patients" onto wards that were already full and short-staffed was unsafe.

Loughrey said it was a "potential mitigating step".

He said: "If one department of a hospital has 20 extra patients, it may be preferable that the wards share some of that burden and each take one extra patient.

"That's not without risk - it's not managing patients in appropriate clinical areas, and it's not that those wards are adequately staffed. Many are struggling with staffing.

"But it might be better than what we are currently seeing, which is patients spending four to six or more hours in ambulances waiting to come into emergency departments. That's a real measurable harm.

"It shouldn't be taken as the solution though. We have to attend to the long term fixes: namely social care, more beds, and retention of staff."

In December, the percentage of patients seen, treated and subsequently discharged or admitted within the four hour target fell below 60 per cent for the first time, despite A&E attendances remaining lower than pre-Covid levels (Image: PHS)

One emergency medicine consultant, speaking on condition of anonymity, said frontline staff were effectively suffering from post-traumatic stress disorder (PTSD) as a result of the repeated "moral injury" of being forced to provide substandard care.

They said: "It's intensely stressful watching people deteriorate in front of you in corridors. If you put anybody in a noisy, highly lit environment for 24 hours that's almost torture.

"You're sitting there with ambulances queued outside and you're just waiting for the hammer to fall.

"You're sat there in a state of high anxiety waiting for the problem you can't solve: the patient having a cardiac arrest and you've got nowhere to put them; the patient who was unwell suddenly deteriorating with nowhere to sort it out.

"You're playing Russian roulette on every shift you go on, but you've got three bullets in the chamber instead of one. That is what wears you down - that's traumatic.

"I arrived at work one day and there were three ambulances parked outside and I thought 'oh, that's good' - five years ago that would have been unheard of.

"Staff learn to accept substandard care. You start to forget what good care is."

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The consultant said they knew of some colleagues who had now left the NHS completely to set up private clinics, while others are taking on more work in the private sector - rather than the NHS - where their earnings exempt from costly pension taxes.

They warned that this would only destabilise the NHS without increasing the overall healthcare capacity available to the population

They said: "The public don't know what's going on. They think that private sector capacity is additional to the NHS somehow.

"They don't understand that it is, with very few exceptions at the moment, doctors who work in the NHS who also do the private work.

"[In the 1990s] Labour had doctors work in the NHS for enhanced rates to solve the backlogs; now doctors aren't going to do that for reasons like the pensions tax.

"There is a total healthcare capacity in the UK made up of private and NHS and it doesn't matter how much is done in either, it's not getting bigger unless you add more doctors and nurses to it.

"The public think the private stuff is unlimited and different from the NHS, whereas it will denude NHS capacity [while] the private sector is very quickly going to run up against the same constraints.

They're going to have waiting lists relatively soon unless they can get new staff in."

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Patients waiting for hip and knee replacements have already experienced some of the biggest delays as a result of the pandemic.

By the end of September last year, there were more than 11,000 patients on orthopaedic lists who had been waiting over a year for planned surgery - including nearly 2000 who had been waiting over two years.

In December, as beds ran out, several health boards paused all elective orthopaedic operations until at least the end of January.

Jacqui McMillan, an orthopaedic surgeon and member of the BMA's Scottish council, said her own health board - NHS Ayrshire and Arran - had continued but was now "feeling the pressure".

She said: "There's been a huge amount of work done in dealing with ambulances waiting outside A&E and getting flow happening for the emergencies, but what we have now are wards full of people with respiratory illnesses and they're spilling over into other wards so that we can't get elective patients in for surgery."

Another problem, said McMillan, is that patients admitted now for hip and knee replacements are slower to recover which ties beds up much longer.

"They are on more painkillers, they're less fit, they're de-conditioned - they're different people that the ones we put on the waiting list a year and a half ago or longer."

In Devon, Cornwall and Bristol, NHS trusts have begun discharging patients who are medically fit into local hotels to free up desperately needed beds while care packages are arranged.

They are looked after in the hotels by staff from private care agencies employed by the NHS.

McMillan said she had seen similar schemes used when she worked as doctor in Toronto, Canada.

She said: "Patients came from three hours away and if they needed a bit more time before they went home they went to the hotel next door.

"I think they're possibly okay for patients who are medically fit but need social care, but that's not most elective orthopaedic patients who will require rehabilitation.

"But the question would be, how do you staff it - and who with?"