“And we are facing a lot of aggression. In the past, a wait of two or three hours would have been seen as excessive. Now we are going into houses where patients have been waiting 25 to 26 hours. Maybe they’ve fallen and fractured their hip and they’ve been unable to go to the toilet or to the kitchen to make a cup of tea - so you can imagine the anger and frustration.
“We are going into a hostile environment and saying: ‘We are so sorry.’ We are not trying to justify the situation. We know it’s unacceptable. Morale is at rock-bottom because we feel we are failing those patients, but there is nothing we can do about it.”
Richard* is a paramedic in the Highlands. Several of his colleagues have been physically assaulted in recent weeks. "But there are also people who, because of the publicity, aren't contacting the ambulance service when they ought to," he says. "They don't want to bother us. Yesterday, I had a mum with a sick kid who felt guilty about calling us, but the kid did need to go to A&E."
Richard says worries over patient safety are damaging morale. “People always ask the inappropriate question: ‘What’s the worst thing you have ever seen?’ They think it will be a car crash," he says. "But the most depressing thing is some of the social situations you find people having to try to cope with.
“You turn up to an elderly person who’s been on the floor for 12 hours and something that could have been a simple fall then turns into something much worse. It’s the more vulnerable people that are being impacted by the delays and that does get to you.”
The paramedics are speaking out anonymously after a fortnight in which the news has been dominated by the burgeoning crisis in Scotland’s NHS.
The initial spotlight was on the ambulance service which has been facing an unprecedented surge in demand. Last month, crews responded to 10,733 life-threatening incidents compared to 5,788 in August 2018.
Tom, who also does shifts telephone triaging for ambulance control, says one night last month, there were 270 outstanding “yellow” calls across the country. Yellow calls are those considered the lowest priority, but are still emergencies. “On any given day, we will have 120 paramedics on duty. If those 120 paramedics are out on emergencies and there are 270 emergencies still waiting to be allocated, you can see how the delays begin to stack up.”
Health Secretary Humza Yousaf apologised to families after it emerged a Glasgow pensioner had died after having to wait 40 hours for an ambulance. He said the Army would be called in to help and announced an extra £20m to recruit 300 more staff.
But it quickly became clear the ambulance delays were merely the most obvious manifestation of a crisis that runs much deeper. Last week, it was revealed A&E waiting times had hit a record low for the fifth time in six weeks. Just 71.5 per cent of people visiting A&E in the week to September 12 were seen within four hours, a drop from the figure of 74.6 per cent the week before. The Scottish target is 95 per cent.
Much of the explanation for the poor ambulance response times lies with the problems in A&E. Ambulances are “stacking” outside hospitals as paramedics wait hours to have their patients admitted.
Tom believes pressure on the ambulance service is being increased by the decision to move team leaders off frontline duties to deal with the logistics of Covid - a measure he says was necessary at the time, but should no longer apply.
“But hospital turnaround times is our biggest problem by a mile,” he adds. “Generally speaking before Covid we had a 20-minute turnaround time. This means that from the moment we pressed the arrive button on the screen, we had 20 minutes to transfer the patient into the department, clean the vehicle, make sure the paperwork was done and remobilise. That’s no longer a target because everyone knows it is impossible and most of these delays are outwith ambulance control.”
Richard says one night last week, there were six ambulances queuing up at Raigmore Hospital in Inverness. These included all three of Inverness’s ambulances and three ambulances from outlying stations. “This means huge areas are uncovered,” he says. “It means there is no local response.”
Delays in admissions to A&E are being caused by blockages further down the line. Emergency medicine doctors are unable to move patients on because the wards are full. And the wards are unable to discharge elderly patients who no longer require medical treatment because they are waiting for a care home place or a community care package.
The whole system is clogged. While researching this piece, I heard the phrase “a perfect storm” repeated by GPs, paramedics, nurses, hospital doctors and managers. This “perfect storm” is being caused by, among other things: a spike in illness caused by the easing of restrictions, the Covid backlog, burn-out and Brexit.
“What people don’t understand is that [the NHS] is like a pipeline,” says Esther Roberton, former chair of NHS 24 and NHS Fife. “As a result of this perfect storm, we have more people going into a pipeline that is narrower than it has ever been because of Covid restrictions, a system that is running hotter than it has ever run because the staff are working their socks off to try to clear the backlog, and the exit from the pipeline is slower because of delayed discharge which is caused, in no small part, by the difficulty of recruiting social care staff as a result of Brexit.”
It is September - normally a period of comparative lull before the winter rush. But this year, demand is already at winter levels. Health workers whose resources have been sapped by 18 months of the pandemic, are bracing themselves for worse to come. And the days of banging pots in support are gone. They are operating in a climate of increased political and press negativity which feeds into public perception. This is worse in England than Scotland, but still, there is a sense of panic.
“To think any politician or medical person or health board chief executive can wave a magic wand is a mistake,” Roberton says. “They can’t. They are doing their best. Are there things they could do better? Yes, I’m sure there are. They must be exhausted - everyone is exhausted.”
South of the border, GPs have found themselves under attack. While Yousaf praised the efforts of Scottish GPs, UK Health Secretary Sajid Javid sent their English counterparts a letter ordering them to resume face-to-face consultations (which GPs insist have never stopped). “It’s been better in Scotland,” says Dr Iain Morrison, a partner in an 18,500-patient practice in Dalkeith. “But that doesn’t mean what happens in England isn't having an effect on morale here.”
The face-to-face narrative is simplistic. It is true surgeries reduced footfall during Covid, as they had to. But - long before the pandemic - surgeries like Morrison's were already reviewing the way they operated. Demand was outstripping capacity to the extent patients were waiting two to three weeks for an appointment. Not only was that unsustainable for those patients, it also led to a higher rate of non-attendance.
Morrison’s practice had been operating telephone triage since 2011 and had introduced eConsult - a form of online consultation - just before Covid-19 took hold. While it is important to mitigate against digital exclusion, not having to always traipse to the surgery suits many people. In addition, proper triaging frees up physical appointments for those who need them most.
Covid speeded this process up. It meant surgeries which had been slow to embrace technology were forced to do so, but Morrison describes the notion face-to-face appointments stopped as “a fallacy”.
“I don’t know what the political agenda is on pushing this narrative because it is untrue,” he says. "Where there has been an identified need for physical examination it has been done. And over recent months as measures have been relaxed, face-to-face activity has expanded accordingly.”
Technology has increased efficiency but it has not prevented GPs from becoming overwhelmed. During the pandemic, when operations were cancelled, patients who would previously have been referred, treated and moved out of the system, have been returning week after week.
“We are handling significant numbers of people awaiting definitive intervention from hospital services,” says Morrison, a member of the BMA’s Scottish GP committee and chair of Lothian Local Medical Committee (LMC). “Take someone who is awaiting a knee replacement. We will see them repeatedly for analgesia, physiotherapy and joint injection but the only real cure is the replacement.”
Dr Iain Kennedy, a partner in a group of three Highland practices and medical director of the Highland LMC, says they are suffering the consequences of pent-up demand. "Our patient population has got older and frailer, it has put on weight, the mood of our patient population has dropped.”
GPs have also seen an upsurge in respiratory viruses such as RSV, which causes bronchiolitis in children, and bocavirus. This may be due to the easing of restrictions after a long period of limited social mixing. “It’s leading to a huge number of contacts and a large number of hospital admissions,” says Morrison. “The fear is if this early surge continues, it’s going to be a major strain on all services.”
Added to that is the potential threat of flu, the impact of which is as yet unknown, although it is hoped the flu vaccine campaign will keep it under control.
“On the Tuesday after the Bank Holiday, we received 493 appointment requests between 8am and 6pm - higher than the busiest day ever in the Edinburgh Royal Infirmary A&E department and in A&E it’s spread over a 24-hour period,” Morrison says. "We represent 2 per cent of Lothian - so multiply that by 50 and you get an idea of the scale of the demand.”
As with the paramedics, patients’ frustrations sometimes spill over into abuse, although in this case it tends to be the receptionists on the receiving end. “They are the unsung heroes of the pandemic and they should not have to put up with it,” Morrison says.
Things are no better in A&E. Dr John Thomson is a consultant in emergency medicine at Aberdeen Royal Infirmary and Vice President (Scotland) at the Royal College of Emergency Medicine.
He says - bad though they are - last week’s headline figures aren’t the worst of it. “They show that last week there were more waits of more than eight and 12 hours than we have ever had on record, but that doesn’t tell the whole story,” he explains.
“We know in some emergency departments, some patients are waiting significantly longer, up to 48 hours on occasion, to be admitted to a ward. You can imagine a doctor or nurse coming off one shift and then back on the next, and the same patient is still in the department. It’s awful for that patient and demoralising for staff.”
To the problems already discussed, Thomson adds the lack of acute beds. The Royal College estimates the country is 1,000 short. Six hundred of these were cut pre-pandemic as hospital stays became shorter. “The plan has been to provide care closer to home but unfortunately there hasn’t been the expansion of community services in line with the reduction of beds,” Thomson says. A further 400 beds have been lost as a result of physical distancing.
“That is contributing to long stays in A&E. It's a challenge for us because we are not trained to provide ward-level care, we are trained to manage critically unwell, critically injured patients in the first few hours of their presentation.”
Even were the number of beds to be increased, a higher than average absence rate means there wouldn't be enough staff to manage them.
“Most emergency departments are operating with reduced staff," Thomson says. "We don’t fully understand at this stage the physical and mental impact of the pandemic on health workers, but it is likely to be a chronic problem."
The logjam affects every part of the health service. Gillian* is now a critical care nurse in a busy city hospital. Newly-qualified, she was moved from a surgical ward to a Covid ward in March 2020 and has barely stopped since.
At the moment, she is supposed to be working in surgical high dependency but, because of staffing issues and demand, she has been alternating between surgical high dependency, Covid critical care and the ICU. “The critical care unit is all one just now, as opposed to three or four different work spaces with their own separate staff. We are having to pull together,” she says.
Absence rates are a particular worry there because of the ratio of care: two patients per nurse in high dependency and one-on-one in ICU. “You are coming in every day, you know how stretched it already is and you are seeing the numbers increasing,” she says. “There’s the daily uncertainty of not knowing if you are going to be working in your own area or if you have to be in the Covid area again. Sometimes you have to move half way through a shift because more patients are arriving.”
Gillian is not suggesting staffing levels are unsafe, but says, “sometimes we have had to get the wards to hang onto patients a bit longer until we can get the new shift on - of course, we would always risk-assess that decision. The members of the multidisciplinary team are always talking to each other and thinking, who is our fittest patient? If we need a bed, who can we step down?”
But the problem for critical care is the same as for A&E. There may be no room on the wards for those deemed fit enough to leave high dependency because those fit enough to be discharged from the wards have nowhere else to go. “It becomes an issue where you are having to almost negotiate and fight with the bed managers in the wards because if patients stay in high dependency [when they no longer need to be there] it means someone else who does need to be there cannot get in.”
Though she says it has aged her, Gillian has no regrets about becoming a nurse. She believes she has gained experience that would have taken her years to accrue without the pandemic. But she has seen others leave for jobs that don’t involve face-to-face contact, such as with NHS 24.
“Fair enough they’re doing an important job, a good job, but the impact they could be having in critical care, doing what they are meant to be doing, doing what they trained for - it’s such a loss.”
Staff recruitment and retainment - as well as staff absence - is an ongoing issue across the health service.
Kennedy says the Scottish government guaranteed 800 additional GPs back in 2017 - those GPs have not appeared - and a shift towards multidisciplinary teams including pharmacists, physiotherapists, mental health nurses, an urgent care service and community link workers, to ease the GPs’ workload.
“That was supposed to be delivered by April of this year, but unfortunately it has been delivered patchily,” he says. “In reality, all we have received is a pharmacist and a physiotherapist.”
In the last 18 months, Kennedy’s practices have lost seven of their 14 GPs including two partners. “One partner retired, another decided to move with his wife who is a surgeon to work in South Africa,” he says. “Of the salaried doctors, one took his family to New Zealand, while the other four have gone to competitor practices in Scotland.”
Meanwhile, the paramedics are seeing soaring sickness rates. “It’s not because they have Covid,“ says Tom. “It is because they have burnt out. It used to be that when people went off with stress after a really awful job, they would get some support and be back in two or three weeks. Now they are going off for months.”
In the short-term, Yousaf is pressing ahead with his Army plans. Some 114 military personnel have been drafted in with soldiers starting to drive vehicles from this weekend.
Earlier this month, Nicola Sturgeon confirmed £2.5billion in extra NHS funding to be spent by 2026/27. Her Programme for Government pledged to establish a network of cancer diagnostic centres, refurbish NHS facilities across Scotland and invest in mental health services.
The Army input should help alleviate the ambulance crisis, freeing up paramedics to treat those suffering medical emergencies at the scene, though it will do little to prevent the stacking of vehicles outside hospitals and could even exacerbate the problem.
But Richard says there needs to be more focus on what is happening in the hospitals. “The whole urgent admission set-up needs to be looked at,” he says. “That’s the thing that would stop the bottleneck and free up the resources because it’s going to take a while for the extra recruitment to kick in.”
There are those, too, who feel the Scottish government has to do more than constantly throw money at the sharp end of the NHS; that, in the long-term, the answer is not to expand hospital services but to prevent people from being admitted, and ensure those who are admitted can be treated and discharged as quickly as possible.
“The focus is often on the sharp end because people keep reading scare stories about ambulances and hospitals and the visible, high-risk end of the health service and, of course, if it's your mum lying on the kitchen floor waiting, that's the bit you care about,” says Roberton. “But my belief is that it makes it harder to invest in the earlier stages of the process.
"It's easy to tell scare stories about individuals but managers and chief execs and politicians are having to make whole-system decisions. For me, the single thing that would help the problem we are facing now is if we could address the challenges of social care and resolve that end of the pipeline, though, as I have said, Brexit has made that more difficult.
"Maybe what we need in the longer term is to invest more in reducing poverty, which would improve health and reduce the pressure on the NHS because fewer people would need to use it.”
Some names have been changed to protect their identities