Where are we heading with A&E gridlock and demands of care sector?

The NHS in Scotland is in the grip of two parallel crises: A&E gridlock and a care sector where demand far outstrips supply.

Unless we fix social care, hospitals will remain overcrowded and inefficient – so where do things stand, and where are we headed?

A&E emergency?

Emergency departments in Scotland are performing better than they were in winter – that's pretty much inevitable – but the picture remains virtually unrecognisable compared to 2016.

Since then, Brexit has complicated the recruitment and retention of EU workers (particularly for lower-paid jobs as carers) while Covid drove many more to quit care homes for less stressful, better-paid jobs in retail or hospitality.

Back in May 2016, just 80 patients in the whole of Scotland spent more than 12 hours in A&E departments. By May 2023, the figure was 3,716.

This has nothing to do with an increase in attendances, which continue to be lower than they were pre-pandemic (138,467 in May this year, versus 148,514 in May 2016).

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Nor has there been an increase in emergency admissions; in fact, these have fallen from a rate of 12,229 per 100,000 in 2016/17 to 11,155 in 2022, according to a report last week from Public Health Scotland.

The reason patients continue to be stuck for hours – or days – in A&E is because there is nowhere for them to go. Wards are full – sometimes operating well over-capacity, with two patients to one-person bays, trolleys in corridors, or storage rooms converted into makeshift wards.

The main reason is "delayed discharge": the patients ready to leave who cannot get out of hospital.

Limbo

In February 2015, Scotland's then-health secretary Shona Robison pledged to eradicate delayed discharge by the end of the year. Eight years on, the problem is worse.

In July 2016 (the earliest month for which data is available), an average of 1,417 beds a day were occupied by patients ready to leave hospital; by May 2023, the figure was 1,744.

Over the same period, hospital bed numbers were also cut – from around 13,644 in 2016/17 to 13,323 by 2021/22 (figures for 2022/23 are not yet available but will continue the downward trend).

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This is important because it means that patients affected by delayed discharge are occupying a larger share of NHS beds – roughly 13-14% now, compared to 10% back in 2016.

That might not sound like a dramatic shift, but it is: it means that approximately one in seven beds are being used unnecessarily, instead of one in ten. Or, to put it another way, the number of beds being lost in this way is around a third higher now than it was in 2016.

Who's stuck?

Two thirds of patients with a 'delayed discharge' are over 75, but the problem is growing fastest in the 18-74 age group who accounted for 628 cases in May this year compared to 424 in July 2016 (a 48% increase, compared to a 12% increase over the same period for over-75s).

Most cases of delayed discharge (73% in May this year) were due to a lack of available social care. The majority (409) involved patients waiting to return to their own home, followed by 315 who were waiting for a place in a nursing home or residential care home.

Delayed discharges due to complex 'Code 9' reasons are also on the rise, however. These now account for 27% of bottlenecks, compared to 21% in 2016.

Most Code 9's involve adults with incapacity, such as severe learning disabilities.

Notably, residential care home places for adults with learning disabilities have disappeared ten times faster over the past decade than those for older people – a reduction of 35% versus 3%.

Alarm bells?

On Saturday, Scottish Care – which represents independent care providers – warned that recent months have seen the "largest number of care home closures" ever experienced in the sector.

At least eight premises de-registered between January and March, according to Care Inspectorate figures, compared to an average of 5.7 closures per quarter from 2015 to 2019.

There are fears that this will "accelerate at speed" because the latest funding settlement, which increases by 6% the amount local authorities have to pay care homes for each council-funded resident, is too low to raise staff pay to £12-an-hour or offset other cost of living pressures, such as energy costs.

Self-funded residents will bear the brunt as fees are hiked.

Meanwhile, a survey on Tuesday from the Coalition of Care Providers Scotland (CCPS) found that 88% of its members were finding it "very difficult" or "quite difficult" to fill frontline posts in 2022, with 81% reporting their recruitment needs had increased year-on-year.

On average, staff turnover stood at 25%, up from 19.5% in 2020/21.

If social care unravels, it will take our hospitals and A&E departments with it.

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