Bed Bound: The chronic problem of delayed discharges is tying up resources across the NHS

With Scotland’s NHS seemingly in a state of permanent crisis, John Swinney recently began taking a more hands-on role in administering to its needs. It emerged the first minister was chairing weekly health service meetings while personally overseeing the response to a surge in winter flu cases which brought already embattled hospitals to the brink. Opponents said health secretary Neil Gray – currently at the centre of a mini-scandal about the use of government cars to attend the football – had been “sidelined”. But Swinney – himself assailed with NHS failures on a regular basis at First Minister’s Questions – knows that with an election on the horizon, the performance of the health service has to improve.

Yet even as the first minister apparently redoubled his efforts to address the deep-seated problems across the system, one of his government’s most ambitious reforms, the National Care Service (NCS), fell by the wayside. A casualty of the Scottish budget negotiations, the NCS had been on a shoogly peg since the Scottish Greens withdrew their support in the autumn, removing the prospect of a parliamentary majority for the legislation. Described by former first minister Nicola Sturgeon as the “biggest public sector reform in Scotland since devolution”, development of the proposal had managed to alienate just about every one of the government’s key partners responsible for its delivery, with local councils accusing ministers of a “power grab”. 

Reflecting on her time in government recently, Sturgeon said she believed trade union and local government “hostility” to the plans had been “manageable”. “When I left office, I thought it was a very significant challenge, but one that was absolutely do-able and one that was really important to do,” she said. “I think it’s regrettable that for whatever reason it seems to have run as deeply into the sand as it has.”

But while opposition to the government’s plans to reform social care ultimately made them unworkable, it was nevertheless an attempt – however limited – to get to grips with one of the greatest policy challenges of our time – one that governments both at Holyrood and Westminster have baulked at. That’s because while it will need a Herculean effort, fixing social care will drastically reduce pressure on Scotland’s hospitals. 

According to figures published last week by Public Health Scotland, there were 1,890 so-called delayed discharges in December. While that figure represents a reduction from November (2,020) and October (2,030), it nevertheless shows that nearly 2,000 hospital beds are being occupied by someone well enough to leave. The equivalent of 61,706 days was spent in hospital in December by those whose discharge was delayed – up six per cent on the previous year. And while the median wait for discharge is around a month, it is not uncommon for some patients to spend many months in hospital waiting to go elsewhere. 

Health secretary Neil Gray meets staff | Alamy

“The typical people who are stuck are older people,” says Dr Patricia Cantley, a geriatrician and member of the Royal College of Physicians of Edinburgh (RCPE). “You do get some younger people who are stuck as well and that’s different because you’re often dealing with different legislation, different rules, different departments. And they are more likely to have housing issues. There are a few younger people with significant disabilities in the system as well, but your classic person who is stuck is older; many will have dementia, but not all do.”

The RCPE wrote to Swinney at the end of last year calling for additional funding to address the “urgent” issue of delayed discharge, noting there had been an 18 per cent fall in the number of care homes, and a six per cent drop in registered places, over the past decade. It called for more investment in community care services; improved financial support for family caregivers; increased funding to improve coordination between hospitals, social services and community care providers; and increased implementation of technology to help track the progress of patients. In short, an increase in spending across the board.

If further evidence was needed of just how pressing the issue is, it came in a report from the Royal College of Nursing (RCN), released last month, which laid bare the extent of the ‘corridor care’ crisis in Scotland’s hospitals, with patients being treated in commandeered side rooms and storage cupboards, such is the pressure on beds. One nurse said that due to a shortage of beds on her ward, a doubly incontinent elderly patient who needed space in private to be cleaned was put in the charge nurse’s office. Another said a “very confused” patient was deemed fit enough to be housed in a corridor despite repeatedly wandering off. Eventually a bed was placed in an office normally used for outpatient appointments, which had no window or toilet but a desk with a computer. A third said she felt “disgusted and ashamed” at the quality of care offered to a 91-year-old female patient. 

Swinney has referred to delayed discharge as the “canary in the coal mine” of Scotland’s NHS, an early indicator of a system struggling to cope. He has pledged to “strengthen and renew” the health service by shifting care out of hospitals into the community and people’s homes. One way of doing this will be with the introduction of ‘frailty teams’ at the front doors of A&E departments to triage elderly patients and reduce pressure on hospitals. Critics accused the government of creating “granny bouncers” who would block access to emergency departments for older patients, but Cantley dismisses that suggestion. 

“This allegation of ‘granny bouncers’, the person at the front door who is going to turn you away, is rather laughable because to turn somebody away at the front door takes a lot of time and discussion and professional input.” 

And she says many of those who end up as a delayed discharge were in crisis long before the event that ultimately brought them to hospital.

“Often, we see someone coming into hospital and think we could manage these problems at home. But the challenge is offering the wraparound social care. If you’ve got a family who have been on the waiting list for a care package for many months, they will perhaps grab that opportunity that the person is finally in hospital and being looked after.”

The government has also promised to extend the Hospital at Home initiative where elderly patients are given treatments such as oxygen or intravenous drips that would otherwise see them admitted. But with competing demands for funding across health and social care, it remains to be seen how much money will be provided for these interventions and ultimately whether they will deliver any benefits.

Analysis of Scottish Government spending carried out by the Institute for Fiscal Studies (IFS) shows that in 2024/25 health and social care was topped up by an additional £1.5bn over and above the figure initially set out in the budget in December 2023. That means that rather than a 2.7 per cent cut in real terms, day-to-day spending on health and social care increased by 5.2 per cent in the current financial year.

“That’s a big turnaround,” says David Phillips, the head of devolved finance at the economic think tank. “A five per cent real terms increase is more than you’d expect to be needed just to stand still. That’s the amount of money you’d expect would be helping improve services. When it comes to delayed discharges, there’s been more money going into the NHS and social care… you would hope that would begin to lead to improvements. The question is, has that been the case so far this year?”

The honest answer is that it’s probably too early to tell, although Phillips says there are some signs of recovery in England’s NHS based on available data. Meanwhile, figures published last week showed more than 180,000 patients waited more than eight hours to be seen in Scotland’s A&E departments, the worst figure on record, while research from the British Heart Foundation found cardiology waiting lists at record levels, with 1,200 people waiting for more than a year for an echocardiogram and more than 750 waiting more than a year to see a cardiologist. 

Behind every statistic is a story, such as Yvonne, a 68-year-old grandmother with MS whose case was raised by Scottish Labour leader Anas Sarwar at FMQs. Despite being cleared to go home, she spent two months in hospital waiting for a care package and took to wearing a T-shirt with ‘Bed Blocker’ on it. Swinney conceded Yvonne’s case was “not acceptable”.

While Scotland once dramatically outspent other parts of the UK on health, the gap has been closing in recent years. At the outset of devolution, spending was 22 per cent higher per person than in England, but by 2019/20 this figure had fallen to three per cent. And while Scotland continues to spend more per capita on social care than England and Wales, 2023 analysis carried out by the Nuffield Trust found that adult social care expenditure had fallen by 21 per cent in a decade north of the border. 

There are indications England's NHS has 'turned a corner' | Alamy

“Since about summer 2023, it does seem things are starting to turn around in England,” says Phillips. “Waiting lists are starting to stabilise [and] there are small improvements in most metrics. The performance is still much worse than before Covid but it’s starting to move in the right direction. Comparing levels [with Scotland] is difficult but you can compare trends. While performance is poor everywhere, it’s starting to turn the corner in England – there’s less evidence it’s starting to turn the corner in Scotland yet.” 

Last year just as councils were pulling their support for the NCS, it emerged the government had already spent close to £30m on the plans, money the SNP’s opponents at Holyrood said would have been better used by being put straight into frontline care. It’s not hard to see how the costs were racked up, however, as the legislation for the NCS was a so-called framework bill, a sort of skeleton outline that would have needed fleshing out at a later date. In truth, £30m is a drop in the ocean when it comes to social care. In the 2025/26 budget, for example, £828m has been allocated to local councils to deliver health and social care services. And while the original cost for the NCS was put at between £644m and £1.3bn over five years, it was thought the final bill could reach £2bn.

Fourteen years on from Andrew Dilnot’s report into overhauling social care in England, the situation across the UK remains largely unchanged despite an ageing population and increasing pressures on the NHS. Last year, Dilnot described Chancellor Rachel Reeves’ decision to scrap planned changes to the care system in England on the basis of cost as a “tragedy”. As pressing as the problem is, politicians seem unable to grapple with the complexity of reforming social care. 

A doctor who has worked with elderly patients for nearly 30 years, Cantley confesses to being a fan of the concept of the ‘magic wand’ and says she often asks patients what they would wish for if she were their fairy godmother rather than their clinician. Sometimes the answers are heartbreaking and beyond what even the best doctor can do – being reunited with a lost loved one or brought closer to a family member who has moved away. Asked what the impact of magicking away delayed discharges would be on the NHS, she says it would be transformational. 

“It would be enormous – you would just free up so much capacity. The wheels would turn so much better.”