'This is no longer a winter problem, this is an NHS in crisis problem'

Just a few weeks before she stood down as first minister, Nicola Sturgeon issued a dire warning about the NHS. Scottish hospitals were, she said in early January, “almost completely full” and, although the winter period was already in full swing, the health service was facing “its worst winter ever”.

“In addition to Covid, the country has been experiencing extraordinary levels of winter flu – more than 1,000 patients were admitted to hospital with flu during each of the last two weeks,” she said during a press conference held to acknowledge the crisis the service was in. “Last Wednesday hospital bed occupancy across Scotland exceeded 95 per cent. For context, at the same stage in 2020, before the pandemic struck, occupancy was around 87 per cent.”

Since then, Sturgeon has relinquished her post at the top of government, the man who was her health secretary at the time – Humza Yousaf – has replaced her as first minister, and the bad news has continued to roll. In the last few weeks alone there has been confirmation that 820,352 people are currently on an NHS waiting list, 77,504 of whom have been waiting for more than a year; that in July a total of 1,897 people were stuck in hospital awaiting discharge, the highest figure so far this year and up 8 per cent from the 1,738 reported in June; that nursing and midwifery vacancies remain stubbornly high, with close to 6,000 roles remaining unfilled at the end of June, a figure that has remained broadly unchanged for the past two years; and that there has been a 14.6 per cent increase in vacant consultant posts in the last quarter, up from 446 to 511 to reach the highest level seen since the pandemic.

Unsurprisingly, with Covid on the rise again, the picture being painted as the Scottish Government’s attention turns to its winter-preparedness plan is bleak.

“It’s fair to say that last winter was the worst in a generation and probably the worst in the history of the NHS,” John Paul Loughrey, vice-president for Scotland at the Royal College of Emergency Medicine, told a recent winter planning meeting of the parliament’s Health, Social Care and Sport Committee.

“Last year the focus was on short-term measures but without a longer-term strategy to avoid further winters like the last one we haven’t really seen any abatement in the pressure on our emergency departments or across primary care and all acute specialties in the summer like we normally would. What we have seen this year is a decrease in our workforce – we are seeing a dwindling of the workforce across all sectors in Scotland. What we haven’t seen so far is any future planning that involves more than just trying to deal with the next winter crisis.

“I asked other royal colleges what they thought of winter planning in general and it’s unanimous that this is no longer a winter problem, this is an NHS in crisis problem and short-term winter reactions is only crisis mitigation. We know we have a workforce problem, we know we have an overall capacity problem, partly as a product of a tenacious number of delayed discharges in hospitals […], we know that over the last 10 to 15 years, with a reduction in the acute and general bed base, that that has probably gone too far. We know we have too few beds in Scotland in order to deal with these winter surges on top of an already over-capacity and over-stretched system.”

This is no longer a winter problem, this is an NHS in crisis problem

BMA Scotland chair Lailah Peel, who is also an A&E doctor in Glasgow, agrees. Though the Scottish Government’s target is that 95 per cent of people attending A&E are seen, admitted, discharged or transferred within four hours, she says the reality is that patients are routinely kept waiting for “nine, 10, 12 hours”. Indeed, Public Health Scotland figures show that in the week ending 3 September only 69 per cent of patients were seen within four hours, with 9 per cent having to wait over eight hours and 3 per cent waiting over 12. On a recent shift, a patient Peel noticed waiting when she clocked off had still not been seen when she returned to work the next day. It is not a situation, she says, that anyone wants to be in as winter approaches.

“I moved to Scotland in 2017 and every winter since then has been ‘the worst winter ever’ and it’s just been compounded,” she says. “There’s no longer any light at the end of the tunnel.

“A&E departments are not designed for people to be in for a long time. We don’t have the staff for a basic service, let alone being so crowded. A&E sees it highlighted more because we rely on the flow through the hospital – I know medical and surgical wards are full because I can’t get patients into them. In summer it was that there weren’t many beds, now it’s that there are no beds. It’s now normal to bed patients down for the night in A&E; food services come to A&E, we give them their routine medicines. Instead of trying to fix it, it feels like we’re just moving around in a circle.”

With a regular stream of stories about people waiting many hours to be seen in A&E and the excess deaths that have arisen as a result, it is unsurprising that much of the focus on the problems in the NHS tends to be on what is happening in emergency departments. But while delayed discharge – so-called bed blocking – has an impact on what people working in those departments are able to do, the imbalance in the system is having a huge knock-on impact for those working in primary care too. Much of the focus of winter planning is on trying to dissuade people from attending hospital, meaning community healthcare teams are having to pick up the slack. However, Loughrey told the parliamentary committee that those teams’ needs are being overlooked as part of the response.

“The Royal College of General Practitioners is concerned that last year’s winter plan, and this year’s, focuses largely on secondary care,” he said. “We know that around 10 per cent of GP practices have had to close their lists and we know there’s a workforce crisis in primary care. We also know that a lot of the strategies around the winter are around attendance and admission avoidance, trying to keep people at home, but a lot of that puts more pressure onto already over-burdened GP surgeries.

“The message around a lot of that seems to focus on avoiding coming to emergency departments and going to see your GP or pharmacy, but a lot of that fails to recognise that those services are already experiencing huge pressure as well and when hospitals and health boards ask GPs not to send patients to hospital that puts a lot of the burden and the risk onto the community.”

Earlier this month Public Health Scotland started its winter vaccination programme, inviting those most vulnerable to becoming seriously ill with flu or Covid to get immunised. Last winter uptake among older age groups was reasonably high – 89 per cent of older care home residents took the flu jab and 91 per cent were vaccinated against Covid – but among the clinically vulnerable it was much lower – 57 per cent for flu and just under 60 per cent for Covid. Despite the figures, Claire Cameron, a consultant in health protection at Public Health Scotland, says immunisation is the best way of protecting not just individuals but all levels of the health service too.

“The winter immunisation programme is really important for winter preparedness,” she says. “It’s really important for protecting people from becoming ill – even healthy people can become ill with flu or Covid, which are infections we can prevent. 

“Vaccination is definitely the best way to protect against flu and Covid infections. The primary benefit of that is for the individual but it does have a big impact on the wider health service as well. The main point of the programme is to prevent severe disease – people who might be hospitalised for Covid or flu. It frees up capacity in the health service and primary care as well. People don’t need to see their GP, are not phoning NHS24 and are not seeking help from community pharmacies. By having vaccinations for what we can prevent we can free up capacity for other things that there aren’t currently vaccinations against.”

With a new strain of Covid – BA.2.86, otherwise known as Pirola – currently in circulation, Cameron says it is vital that anyone offered a vaccine takes up the offer. For Keen, however, there is much more the government needs to be doing to ensure the NHS is robust enough to make it through the winter. While the systemic problems facing the health service require long-term and far-reaching solutions, there are smaller, much simpler things the government could do in the short-term to ease some of the burden being carried by NHS staff, she says.  

“I’d like them to be doing something pretty sharpish, even if it’s a case of acknowledging it’s rubbish and that there’s not much they can do but that they will look at what they can do to mitigate the impact on staff,” she says.

“It’s not just a winter plan – they need to be looking at this short, medium and long term. There’s only limited stuff they can be doing this winter. If they can fix delayed discharge they fix a lot of the problems in hospitals but if they put proper remuneration packages in place people will be happy to cover additional bits here and there [to relieve some of the staffing issues].”

We haven’t really seen any abatement in the pressure on our emergency departments or across primary care and all acute specialties in the summer like we normally would

Remuneration is a thorny issue. In July the Scottish Government confirmed senior NHS staff will be given a 6 per cent pay increase following negotiations with the Doctors and Dentists Pay Review Body, while in August Yousaf, who had said junior doctors would be offered their “biggest-ever pay uplift”, signed off on a 12.4 per cent increase. Yousaf even offered to send health secretary Michael Matheson to England to help negotiate a similar deal for junior medics there. But with public finances coming under increasing pressure – a £2bn shortfall is predicted by 2027-28 – negotiations for the 2024-25 period are going to be strained.

Given what is looming, Peel says the government must also look urgently at the other ways it can invest in its staff if it wants to ensure they remain with the service for more winters to come.

“Ultimately they need to listen to staff and do something to look after the staff,” she says. “I’m genuinely fearful that people are burning out. As doctors it’s really hard to pick up when colleagues are falling apart because we’re really good at covering it up and putting a brave face on it.

"Retention is the key [to the future of the NHS]. We all know what our exit plan will be and we all know when it will come but nothing is really done to retain people. It’s really disheartening how little we invest in our staff in the NHS, but even things like the new night café at the Queen Elizabeth Hospital make such a huge difference because now staff on a night shift can get hot food and sit down with a coffee when they couldn’t do that before.”