NHS and Social Care over winter 2022-23
The Scottish Government has not, at the time of writing, published its winter plan for 2022-23. The health and social care: winter overview 2021 to 2022, published in October 2021, was organised around:
- maximising capacity
- supporting staff wellbeing
- supporting effective system flow
- improving outcomes
The Scottish Government’s plan for adult social care, the Adult social care – winter preparedness plan: 2021-22, published in October 2021, centred around four key principles:
- supporting the social care workforce and unpaid carers
- maintaining high quality integrated health and social care services
- protecting social care users from COVID-19 and wider winter viruses
- working in partnership
There has been an acknowledgement by the Scottish Government this winter may put increased pressures and demands on the NHS and social care.
“I am, nonetheless, under no illusion that the NHS continues to face one of the most challenging winters in its history”Minister for Public Health, Women’s Health and Sport
This blog discusses some of the issues likely to face health and social care services over the winter months.
How is NHS Scotland placed to meet increased demand for services?
Like many areas of the UK, Scotland is currently facing challenges meeting its waiting time targets at emergency departments. From summer of 2021 performance against the four-hour standard has dropped below 80%. The week ending 11 September saw a record low of only 63.5% of emergency department attendances being seen within 4 hours. The week ending 18 September this was 66.2%. This compares to 94.4% for the for the equivalent week in September 2015.
Some people have also been experiencing long waits. During the same week 2,697 people spent more than 8 hours waiting and 998 people waited more than 12 hours. This shows some improvement on the previous week which saw 3,381 people waiting more than 8 hours and 1,266 waiting over 12 hours.
Demand for NHS services normally rises over the winter months with more hospital admissions, due to respiratory system diseases such as asthma and seasonal illnesses such as flu and norovirus.
Increased demand may also have an impact on the NHS’s ability to carry out non-urgent hospital care. Following the COVID-19 pandemic there are still fewer planned operations taking place. In July 2022 there was a 26.8% reduction in the number of planned operations compared to July 2019.
Waiting times are also longer than they were prior to the pandemic.
- 451,020 patients were waiting to be seen (30 June 2022), 46.4% higher than the pre-pandemic average
- Of these 49.1% had been waiting 12 weeks or less. This remains markedly down on the 2019 average (73.4%)
- The proportion and number of patients waiting over 52 weeks increased to 8%
People in Scotland are also waiting longer for treatment.
- At 30 June, 139,584 people were waiting to be admitted for treatment. Compared to the 2019 average the waiting list is 81.2% higher.
- Of these 31.5% had been waiting 12 weeks or less compared to an average of 68.7% in 2019.
Occupancy of hospital beds is also generally higher in the winter months, when more people tend to be admitted to hospital and there can be delays in discharging people.
The average number of available hospital beds in Scotland has generally been decreasing. In 2020-21, there was an average of 12,869 staffed beds for acute specialties. This is a 2.5% decrease on the previous year (2019-20) and a 6.9% reduction to five years ago (2015-16).
NHS England has published a next steps for urgent and emergency care letter and framework which focuses on preparation for winter 2022-23. The letter notes that planning for the coming winter has started earlier than usual, “recognising pressure on the NHS is likely to be substantial”. Planned actions include opening additional beds to help deliver against expected winter demand.
Like elsewhere in the UK, there are recruitment challenges facing both the NHS and social care in Scotland. Audit Scotland has noted that “workforce planning has never been more important”. The Scottish Government published its Health and Social Care: National Workforce Strategy in March 2022. The vision of this strategy is for “A sustainable, skilled workforce with attractive career choices and fair work where all are respected and valued for the work they do”.
While the number of people employed in the NHS has increased over time (12.5% over 5 years), there are still high vacancy rates.
These include vacancy rates of:
8.2% at 31 March 2022, compared to 4.4% at 31 March 2018, in the Allied Health Professions.
7.7% at 31 March 2022, compared to 7.5% at 31 March 2018, for medical and dental consultants.
8.7% at 31 March 2022, compared to 4.5% at 31 March 2018, in nursing and midwifery.
In relation to workforce pressures this winter BMA Scotland’s former council chair said:
“In the context of what’s going on generally in Scotland right now, winter seemed to start in about the third week of July.
We [the NHS] came into this pandemic with a knackered, understaffed workforce. Here we are 21 months later and it’s actually a miracle that it’s as functional as it is, and that more people haven’t either just left or gone off on long-term sick because of the pressures that they’re under.”Dr Lewis Morrison
How are social care services placed to meet increased demand for services?
A delayed discharge is when a hospital patient who is clinically ready for discharge continues to occupy a hospital bed, often as a result of a care package being unavailable. Reasons given for increases in delayed discharges include:
- a backlog of demand in the system
- people requiring more complex packages of care
- staffing capacity.
Delayed discharges are at the highest level since July 2016 (when current guidance was introduced) with 1,828 people delayed in hospital (July 2022).
In July 2022, there were 55,992 days spent in hospital by people whose discharge was delayed. This is an increase of 32% compared with the number of delayed days in July 2021 (42,364), as shown in the chart below.
The Scottish Government’s Winter Overview 2021-22 noted that the Scottish Government were “taking actions to improve planned discharge from hospital, social work assessment, provide interim care and increase access to care in a range of community settings”.
In its report NHS in Scotland 2021, Audit Scotland recommended that the Scottish Government and NHS Boards should:
“Work with partners in the social care sector to develop a long-term, sustainable solution for reducing delayed discharges from hospital”.Audit Scotland
Social care capacity
The Cabinet Secretary for Health and Social Care’s statement to Parliament in 2021 on winter planning stressed the importance of bolstering capacity in the social care sector in order to ensure patient flow and manage demand.
“An additional £15 million to recruit 1,000 additional health and care support staff […] to assist with patient flow and delayed discharge and within community health teams.”Cabinet Secretary for Health and Social Care
Staffing and recruitment have been identified as a current issue in social care. The Coalition of Care and Support Providers in Scotland’s (CCPS) 2021 Business Resilience Survey found 100% of respondents reported difficulties with recruitment. Sixty four percent of respondents reported a lot of difficulty with recruitment, with the remaining 36% reporting some difficulty. The report also discusses issues with service provision associated with income and recruitment difficulties. It found reduced or static income resulted in:
- services running at a deficit and being propped up by reserves
- reduction in services and quality
- greater difficulty in planning development or innovation of new services
- limited capacity to increase service provision in response to stark increases in demand
- a negative impact on staff morale.
Covid-19 and other respiratory viruses
In July 2022, the WHO/ Europe Region released its autumn/winter strategy for COVID-19 and other respiratory viruses. The strategy calls on countries to relaunch mitigation efforts and to be ready to respond to an increased burden on their health-care systems.
The Scottish Government has published information on its winter seasonal flu immunisation and COVID-19 booster vaccination programme 2022 which started 5 September.
“The vaccination programme is a vital step in our plans to address as many of the winter pressures as possible. We are also well aware of the bigger picture.”Cabinet Secretary for Health and Social Care
While the severity of the weather this winter remains unknown, what is apparent is that the already high demand on NHS and social care services are likely to increase and this coupled with cost increases for individuals, NHS boards and social care providers has the potential to make this winter particularly challenging. The Health, Social Care a Sport held evidence sessions on this issue on Tuesday 27 September and the Scottish Government’s winter plan is expected in the near future.
Lizzy Burgess, Senior Researcher, Health and Social Care