The bed crisis behind an unravelling NHS in Scotland

Too many beds in the NHS are being filled by patients who no longer need to be there.

That is bad for the patients, who are being cared for in the wrong place, and bad for the NHS which ends up in a state of gridlock.

How did we get here, and what does it mean for how the health service functions?

Delayed discharge

In the year to March 2024, an average of 1,820 hospital beds in NHS Scotland were being used each day by patients who should have been discharged already. That is the highest daily average since current records began in 2016 and marks a significant increase compared to pre-pandemic levels.

Between April 2016 and March 2020, an average of 1,431 beds were being lost in this way – still far too many – but nonetheless an indication that the scale of "bed blocking" has increased by 27% since the Covid emergency was declared.

To put this into context, it means that around 10% of the beds occupied in NHS Scotland at any one time are now being used by patients who should have left. That puts a major squeeze on the health service. 

Older patients are worst affected because the problem is so closely tied to social care. Patients aged 65 and over account for 65% of delayed discharges.

The main reasons patients become stuck in hospital are waits for community care assessment (14%); for a place to become available, for example in a care home (26%); or for care arrangements to be finalised, such as a home care package (30%).

(Image: Newsquest)
Both care homes and hospitals have reduced bed numbers over the past decade despite the ageing population.

The plan, of course, was to offset this with a community-based social care which would support people to remain well and independent in their own homes.

Instead home care providers are unravelling. An exodus of EU staff in the wake of Brexit and the pandemic was compounded by large numbers of remaining staff – burnt out from Covid – seeking less stressful jobs in retail or hospitality, while others jumped ship to better-paid roles in the NHS.

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More recently, funding cuts and inflation have seen Health and Social Care Partnerships (HSCPs) across Scotland responding to black holes in their social care budgets by cutting services, hiking fees, and closing council-run care homes and cottage hospitals previously used to free up acute beds.

A lack of social care not only prevents people from getting out of hospital, it makes admissions into hospital more likely too as inadequate home care packages cause people to deteriorate, become frailer, and at higher risk of complications such as falls.

President of the Royal College of Physicians of Edinburgh (RCPE), Professor Andrew Elder, said the latest figures should be an "urgent wake-up call for the Scottish Government", warning that the current situation is "detrimental to the welfare of patients" and "severely" impacting the flow of patients through hospitals.

"We need to invest in the entire care sector and social care workforce more than has been the case," he added.

(Image: Derek McArthur)

A&E

One of the areas bearing the brunt of delayed discharge is A&E.

In the week to June 16, a total of 1,169 people spent more than 12 hours in an emergency department. Not so long ago, those sorts of numbers would have been unheard of. During the same week in June 2019, that figure was 47; in June 2016, it was nine.

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If patients need to be admitted into hospital but wards are full (partly due to delayed discharge), they will languish for hours – sometimes days – in busy, noisy A&E departments. Meanwhile, patients who need to be seen in A&E lie on trolleys in corridors or the backs of ambulances.

The dangerous and sometimes degrading consequences were highlighted this week in a harrowing Channel 4 Dispatches documentary by an undercover reporter based for months at the Royal Shrewsbury Hospital in England, but John-Paul Loughrey – vice-chair of the Royal College of Emergency Medicine (RCEM) in Scotland – cautioned that it was "not at all an isolated issue".

"This is in near every ED in the UK," he added.