‘Patients just pile up in A&E’: Nurse reveals how bed blocking remains the root of NHS crisis
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Despite millions being spent on helping patients leave hospitals quicker, delays are still causing suffering
For one nurse discharge coordinator in an NHS hospital, trying to arrange care packages for patients to return home safely is a frustrating story of delays and shortages (Photos: Getty Images)
It should be one of the most rewarding jobs in the NHS: arranging for people who have recovered from injury or illness to finally leave hospital and go home.
Instead, nurses specially tasked with managing how and when patients are discharged are often forced to give them bad news, particularly if they are elderly. It can take several days for people to depart – sometimes stretching into weeks of “bed blocking” – even when they are medically fit, because there is no social care available to help them adjust and survive.
New figures show that an average of 14,036 beds were taken up with medically fit patients in England in the seven days to Sunday 15 January, hovering only slightly below a record of 14,069 set the previous week.
This is a leading factor in the NHS crisis across the UK. No matter whether you speak to paramedics arriving to emergencies hours late before getting stuck in ambulance queues outside hospitals, or to A&E doctors whose departments are overwhelmed with terrible waiting times, most frontline staff blame their problems on discharge backlogs.
Gabriel, whose name we have changed to protect his identity and his patients, has been a nurse discharge coordinator at an NHS cardiology ward in England for several years, with two decades of experience in A&E and intensive-care units prior to that. He monitors and assesses patients while liaising with local authorities to book social care staff from agencies, but councils frequently reply it will be a long wait as they can’t find anyone.
“I’ve got a patient right now who is just waiting for once-a-day care, which is supposedly very easy to allocate,” Gabriel tells i. “But she’s been waiting for four days now and her package of care can’t start for a few more days, so in all it will take about a week for her to leave. She’s in her 80s and she had a heart attack, so it’s very disappointing for her.”
There were 165,000 vacancies across adult social care in England – amounting to 9.2 per cent of roles in the system – according to annual figures released in March. Scotland and Wales also have recruitment problems.
Low pay means the sector finds it hard to hire new workers; around half of care workers are thought to receive earnings roughly level with the national living wage of £9.50 an hour, which is lower than the minimum rate at nine of the country’s 10 largest supermarket chains.
Some people need carers to visit three times a day, while others must go into a care home or have round-the-clock attention. But Gabriel’s patient does not have complex needs. “It’s mainly personal care, like washing, dressing, helping with meal preparations.”
Even the most basic requirements, however, result in frustrating delays. And this isn’t just about patients needing patience. It can be dangerous for them, lengthening their exposure to infections and their chances of muscle wastage.
For nurses and other NHS hospital staff, the inability to discharge patients for days on end is harming standards (Photo: Victoria Jones/PA Wire)
“Most of the people in hospital, they’re old, so they’re immunocompromised,” Gabriel explains. “They get deconditioned very easily while they’re just stuck in bed, instead of transferring from bed to chair or mobilising in some way. Because of staff shortages, sometimes nurses can’t afford time even to help a patient out of bed or walk them to the toilet. It has a domino effect on everything.
“Instead of going home, they wait for a care package for a few days and then you find that they’re developing an infection. Markers will show up in their blood test results, that delays their discharge even longer and they decline while they’re waiting.”
The risks to patients in these circumstances can be fatal and appear to be growing. In Scotland, for example, 566 patients died while awaiting discharge in 2019, a huge rise from 157 deaths in 2015, following years of the NHS becoming increasingly stretched.
The data, released in November through a Freedom of Information request by the Scottish Conservatives, showed that 3,202 patients had died while waiting to leave hospital in the previous eight years, despite an SNP pledge to “eradicate delayed discharge”.
Many nurses are on strike again this week, arguing that low pay is harming recruitment and retention of experienced hospital staff (Photo: Ian Forsyth/Getty Images)
Scotland’s First Minister, Nicola Sturgeon, said this month that “the vast majority of people, somewhere around 96 per cent, do leave hospital when they should”. But she admits this still “creates pressure at the front end of the patient journey” and wants to “speed up” the process.
The methods for doing this are controversial, however. This month, the Welsh Government told NHS staff to discharge people “as quickly as possible” if they are medically well, even if care packages are not available. Doctors have warned that people could die as a result and the British Medical Association has rejected the guidance.
The process of discharging someone is more complex than many people realise, with staff having to complete an average of 50 steps per patient, The Daily Telegraph has reported.
But for Gabriel, form-filling demands are nothing compared to the delays inflicted by poor social care provision.
‘It is a huge problem’
“My cardiology ward has around 20 beds,” says Gabriel. “Patients are admitted to undergo procedures and treatment on their heart. During their time with us, we find out in advance if they will need social care when they are discharged, depending on their age, their mobility, whether they live alone, if their house has stairs.
Hospital waiting times have been lengthened by discharging problems (Photo: Peter Byrne/PA Wire)
He works “hand in hand” with physiotherapists and occupational therapists, who assess the patient in detail. “If they recommend a patient needs care three times a day, we send the paperwork to the social services team at their local authority and coordinate with them. They source a domiciliary care agency who can fulfill the care package, and I have to wait until that’s ready.
“We inform their relatives, make sure they have their keys, book transport if they need it, arrange for them to be visited by the therapy team. If they require equipment – like a commode, a hospital bed, a key safe, a pendant alarm – we order that as well. We ensure they’re supported, so even if they’re frail and living alone, they don’t bounce back to hospital.”
After sending details of what a patient needs to their local authority, however, Gabriel often has to follow that with a phone call the next day, when he’s told what he’s been fearing.
“They don’t have capacity for days. They can’t source an agency to do the care, they have lots of people waiting. If the patient lives miles away from our hospital, it can take even longer, and social services normally only work Monday to Friday.
“They’re trying their best. I’m sure they’re aware of the situation in the NHS, that the hospital is in need of beds. But everything has to be set up and it takes time.
Ambulance response times have also been hampered by discharging delays (Photo: Hollie Adams/Getty Images)
“It is a huge problem, especially for emergencies. There will be lots of people waiting in A&E who have had heart attacks, but before they can be admitted, we need a bed in the cardiac unit, so they just pile up in A&E… What we are experiencing right now is nothing new, but it’s getting worse. This has been a long-term problem.”
Some statistics have suggested higher national mortality rates in England could be the result of hospital discharging delays – perhaps costing as many as 8,000 lives in 2017, when the situation was better than it is now – though the extent of this link has been disputed.
Sir David Nicholson, the former NHS England chief executive, argues that “almost all” data on delayed discharges is “designed to show how bad social care is”. He believes it is “wholly useless in terms of trying to operationally improve discharge” and a more local focus is needed.
Lengthy delays cause anxiety among patients, says Gabriel. “They come to us moaning, asking: ‘When is my care going to be available?’ They want to go home.
“Most of them live on their own and come in as emergencies. They’re really stressed about their health but also lots of other things: what’s happened to their house? The heater hasn’t been on for a long time, the food in the fridge will have gone off – who is looking after their pet?”
Why the Government’s extra help is having ‘little impact’
Steve Barclay, the Health and Social Care Secretary, realises the problem in England needs addressing. Last week, he told Parliament: “In June 2020, there were just 6,000 cases of delayed discharge per day – those patients ready to leave hospital who are medically fit to do so – whereas throughout last year, it was between 12,000 and 13,000 per day.” This amounts to around a third of all beds.
The Government has been trying to take action. It announced a £500m Adult Social Care Discharge Fund in September, followed by an additional £200m this month to provide patients with stays of up to four weeks in community care until the end of March. It is also block-booking beds in residential homes.
Six “National Discharge Frontrunners” are also being trialled across England. The Department for Health and Social Care (DHSC) says these potential long-term solutions “include dedicated dementia hubs, new offers of provision for rehabilitative care and creating effective data tools to help manage demand”.
But experts say the financial boost has been bungled. The initial £500m “was slow in getting through to council and NHS commissioners – delays which some Whitehall insiders suspect might be aggravated by ministerial churn”, according to Richard Humphries, a senior policy adviser at the Health Foundation, a charitable research and campaign organisation.
“Details of how the grant was to be allocated were not announced until November, with a first tranche of 40 per cent of the grant not due to go out until December and the remaining 60 per cent to be paid in January.”
Steve Barclay announced on 9 January that another £200m will be spent buying thousands of extra care home beds to speed up discharging (Photo: Jonathan Brady/PA Wire)
The extra £200m was announced “before the first grant had even reached the front line,” Humphries adds. “No wonder care providers complain the money isn’t getting through and this large sum has so far had such little impact.” There are also frustrations at the “convoluted way the money is being distributed”.
“There is a deeper lesson about the Government’s continuing reliance on last-minute, short-term, hand-to-mouth cash bungs to fund social care instead of a sustainable long-term plan for funding and workforce,” he concludes. The funding “could well become a case study in how to disburse a large amount of public money to so little effect”.
More widely, the DHSC says it is “taking urgent action to boost capacity and resilience”, which includes “delivering 50,000 more nurses, increasing the number of NHS 999 and 111 call handlers and creating the equivalent of at least 7,000 more beds. There are also record numbers of staff working in the NHS and we have commissioned NHS England to develop a long-term workforce plan to help recruit and retain more staff”.
An “air gap” between health and social care contributes to handover delays, risking the health of patients throughout the system, according to an ongoing report by the Healthcare Safety Investigation Branch. It also highlighted the inability of many care providers to accept new patients or residents over weekends.
But the pressure to get more patients out of hospital at faster rates increases the risk of them being placed in care that isn’t right for them, at the cost of their health.
Senior figures in community and social care have recently warned that more elderly people are being “warehoused” in care beds that aren’t right for them, sometimes in restrictive long-term arrangements. This has led to people’s health suffering and them being readmitted to hospital, they told the Health Service Journal.
Lack of suitable housing for homeless patients also causes problems, says Gabriel. “Because they don’t have any place to go, they stay in the hospital. They might end up with us for two weeks, minimum.
“Each local authority should have emergency accommodation for them, but some of them don’t have enough funds. And if the patient has had a heart operation, sometimes temporary housing is not appropriate for them. They can’t be just discharged into any sort of environment. That’s a problem.”
Nurses demonstrating outside Great Ormond Street Hospital, as the Government considers a move to limit their ability to strike (Photo: Vuk Valcic/Getty Images)
Nurses in England are angered by a pay increase that is significantly below inflation, but also burnt out while covering for NHS staff shortages – which they say are worsened by low salaries. As well as making their jobs tougher, they agree with the assessment that up to 500 avoidable deaths may be happening every week because of delays in emergency care.
The RCN has called for 5 per cent above the RPI rate of inflation, which is currently 14 per cent – whereas NHS staff have been given an average of 4.75 per cent in England and Wales.
“Pay wise, it’s absolutely rubbish,” says Gabriel, who is in his late forties. “That’s why people are striking. Nurses are overworked, underpaid and undervalued.”
He is from South East Asia and moved to the UK in the late 90s when he was recruited by a London hospital. “The staffing situation has been a problem in this country for decades now. That’s the reason why I came to this country, because the NHS didn’t have the staff.”
Paramedics are also continuing their strike action this month (Photo: Annabel Lee-Ellis/Getty Images)
While discharging delays make his role stressful and frustrating, the job is still a welcome refuge from his previous work.
“I was an intensive-care nurse for 14 years, in specialities like cardiac and neurosurgery, as well as general (ICU). Then I was a clinical nursing specialist for three years in an acute stroke unit in A&E.
“I have done my bit as a clinical nurse. I’ve been at the bedside for almost 20 years here in UK. I needed to slow down a little bit. When I was in intensive care, I did long days, night shifts, weekends – so I looked for a role where I didn’t have to do those. I needed to have a rest. Now my working life is office hours, nine to five, Monday to Friday, no weekends, no nights.”
He was left “exhausted” by working in clinical nursing for so long, he explains.
“Back in 2019, I was in the specialist stroke team. There were only three of us in a 1,000-bed hospital: the lead nurse and two senior nurses. You can imagine how understaffed we were sometimes if someone phoned in sick or went on holiday for a week or more.
“In our A&E, there were eight beds in what we call ‘resus’, where critical patients are brought in. Sometimes all eight beds were stroke emergencies, and you’re the only specialist nurse. The matron and other senior nurses would have to come down to help, but they’re not specialists and can only help with certain things.
“In ICU, you should only have to look after one patient, but they are in a critical condition – they are on a respirator, they are on life support. Imagine if one or two members of staff phone in sick – that means one nurse now has to look after two patients.”
He admits he has been trying to leave nursing altogether for five years and feels sorry for colleagues caring for emergency patients this winter. “A lot of nurses are moving from the NHS to the private sector or doing a completely different thing.”
Gabriel is not striking this week; he is with Unison and voted for industrial action, but members of the union at his employer failed to reach the required threshold for action to be legal.
He is pessimistic about the chance of a deal. “Is it really going to make an impact, or are we just wasting our time? I suspect the Government won’t listen, no matter what.”
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