A year ago, the NHS in Scotland was visibly under strain.
Distressed patients were telling stories of 12-hour waits in A&E and of being "boarded" on the wrong wards due to a shortage of beds in the right places.
Fortunately, there is no sign yet this winter of such serious overcrowding but, unfortunately, figures released yesterday show that the related problem of delayed discharge, commonly known as bed blocking, is getting worse.
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It is important to acknowledge that delayed discharge will never be completely eliminated; nor should it be. Often, people being discharged from hospital have to make life-changing decisions over whether to enter a care home, attempt to carry on living independently or move in with relatives. Everyone deserves a degree of time and space, within reason, to make that decision.
Yet, at the same time, delays in discharging patients are often avoidable. The Scottish NHS is facing a relentless increase in demand caused by the ageing population, so it is a matter of concern when patients who are fit to be discharged from hospital cannot leave. In most hospitals, demand for beds is a constant so, even if a patient stays on for just a few more days, it creates problems such as boarding further back in the system. Some 909 people were delayed in hospital after they were fit to leave in January, the worst figure since 2010.
This is unsustainable. If the NHS is to cope with the growing pressure upon it, cases of delayed discharge must be reduced, not allowed to grow.
Health Secretary Alex Neil has explained the delays by pointing to the fact that 800 care home beds have recently been closed to new referrals after poor inspection reports in certain care homes. It is, of course, essential that patients are discharged only into properly functioning homes but a lack of care home beds is only part of this problem. Often patients are left in hospital while they await an assessment of their capacity for independent living, or because local authority funding for their care home place takes time to come through, or because services to support them living at home are overstretched.
Closer, more effective working relationships between health and social care professionals should in theory speed up the process of patient discharge, and important legislation on integrating those two services was approved yesterday at Holyrood.
Much needed as it is, however, that alone may not be enough. To meet growing demand, it may ultimately prove necessary to increase bed numbers in hospitals. The Herald has been calling for a review of beds and staffing as part of our NHS: Time for Action campaign. A review would assess whether, with its existing capacity, the health service will be able to cope and if not, what extra resources will be required.
If any further evidence were needed of the pressures currently faced by the NHS, it came yesterday in the form of waiting times figures. These showed that the number of patients waiting longer than 12 weeks for a new hospital appointment doubled in a year. The Scottish Government introduced a legally binding 12-week target for treatment to take place after doctors agree a care plan but some health boards are still missing it.
Three months' wait seems eminently reasonable, but health boards' continued failure to meet the target implies that ministers may be failing fully to appreciate the pressures the system is under.
Why has it proved so hard? Once again, the answer is likely to be funding. Finding more integrated, efficient ways of working is crucial, but does the NHS also require more cold hard cash? That conclusion is becoming hard to avoid.
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