Coronavirus: Scotland's hospitals 'jammed' amid signs that pandemic backlog starting to hit NHS

Dr Thomson, a consultant in emergency medicine at Aberdeen Royal Infirmary and vice president in Scotland for the Royal College of Emergency Medicine (RCEM), was speaking to the Herald on Sunday as figures revealed A&E attendances had returned to levels last seen in November 2019.

The numbers on their own are not unusual.

Contrary to popular imagination, A&E attendances actually peak in summer and the 28,493 people who turned up at emergency departments across Scotland in the week ending June 6 was in line with the pre-pandemic average (28,200) for the same week.

What has disturbed medics, however, is the complexity of illnesses and the difficulty finding beds for all those requiring an urgent admission.

A&E attendances are back up to pre-pandemic levels, but doctors are seeing many more very sick patients requiring admission than they would normally expect

This is reflected in the fact that, for each of the past four weeks, more than 100 patients have spent over 12 hours stuck in A&E - some for over 24 hours - a problem rarely seen in summer.

Many of those presenting at emergency departments are also “much sicker” than the usual A&E case mix, leading to fears that hospitals are starting to see the beginnings of a non-Covid surge in demand.

“We’re seeing a lot of patients who have undiagnosed cancer presenting to us,” said Dr Thomson.

“From an emergency medicine perspective, we wouldn’t normally see a high percentage of patients that first present with previously undiagnosed cancer but there is an increased number presenting with acute problems that, on assessment, turn out to be an underlying carcinoma that’s not been diagnosed.

“And undoubtedly, patients with chronic disease - diabetes, heart disease, chronic respiratory disease - that haven’t necessarily sought routine healthcare during the pandemic are presenting now with a sudden worsening of their chronic condition.”

Dr John Thomson, vice president (Scotland) for Royal College of Emergency Medicine

Several patients admitted from A&E have had to be boarded out to surgical beds, says Dr Thomson, because some medical wards are at 120-130 per cent capacity.

This has a knock-on effect for people awaiting a planned operation whose procedure has to be cancelled because there is no longer a bed available for them.

Covid infection control measures also mean patients cannot be left waiting on trolleys in the corridor, but this has resulted in a surge in ambulances “stacking” - queueing up - outside A&E departments instead which are then unavailable to respond to other 999 callers.

“We would cope far better if these were patients attending who we could assess, treat and discharge, but the fact is that they’re needing admission,” said Dr Thomson.

Statistics already paint a grim picture of the non-Covid backlog built up during the pandemic.

Hundreds of thousands of elective surgeries were called off, and as recently as April this year operating theatres were running at two thirds of normal capacity.

The number of dental treatments carried out between April and November 2020 was down by 83% .

Between December and March this year, the number of patients who had been waiting over a year for an inpatient or day case procedure had doubled from 15,000 to more than 28,000, and from 24,000 to 48,000 for outpatient treatment.

Cancer diagnoses were well below average during 2020 and radiologists are now diagnosing many more late-stage, incurable cases

Nearly 4000 fewer people than normal started cancer treatment in Scotland between April and December last year.

Dr Judith Anderson, a practising radiologist in Edinburgh and secretary of the Royal College of Radiologists’ Standing Scottish Committee, said her department is “extremely busy”.

She said: “Multidisciplinary team workloads – where clinicians pool expertise to tackle cancer cases – are the busiest I have seen in my entire career, as we have patients who did not come in for treatment last year now making it into the system.

“In my area of gynaecology, last summer we were covering around 15-20 patients in a weekly meeting – last week we reviewed more than 50.

“All the methods we use to pick up cancer are getting back up and running and patients are coming through for treatment, however, we are also seeing later, less curable presentations of cancer.”

Paediatrics, meanwhile, has been warned to prepare for a “national wave” of Respiratory Syncytial Virus (RSV) following a year-long lull due to social distancing, with one leaked email from a London NHS trust telling clinicians this was “likely to start in July or August”.

The condition usually causes mild symptoms but can lead to bronchiolitis and pneumonia, especially in infants.

The number of elective operations being carried out by April 2021 was still down by a third compared to pre-pandemic levels and waiting lists are increasing

Dr Graeme Eunson, a consultant paediatrician at Borders General, says they are already being hit with a “double effect” of an influx of summer trauma injuries combined with a surge in common winter respiratory infections “that we haven’t seen for 12 months”.

Dr Eunson, chair of the BMA's Scottish consultants’ committee, said his hospital’s A&E department also reported its fourth busiest Monday on record last week.

“There’s a population out there who for the past year haven’t been as fit and active as they would otherwise have been and they’ve become a bit more frail, a little less healthy, and the impact that has on general health is now catching up with people,” said Dr Eunson.

The Scottish Government has set a target for hospitals to get back to pre-pandemic levels of activity by October, something Dr Eunson says will be "challenging" - let alone tackling the backlog.

NHS England has estimated that clearing its waiting lists will require sites to run at 120% capacity for the next four years.

Staffing is one major obstacle, particularly with an anticipated post-pandemic exodus of doctors taking early retirement.

Another is the ongoing threat from Covid and the limits it places on hospital turnover: social distancing means fewer patients can be accommodated in waiting rooms or wards at once; PPE means operations take longer; theatres and CT scanners have to be left vacant longer between patients.

Overall, hospital admissions for the week ending May 23, at 12,102, were actually 23% below pre-pandemic levels - yet some departments are running out of beds.

Even with the vaccine rollout, there is no clear guidance from Government on when and how these limits might be safely rolled back to enable the NHS to properly remobilise.

“What we hoped before the Delta variant came along was that we would slowly be able to move to a position where you could almost treat Covid a bit like flu, but we’re not there yet," said Dr Eunson.

"If we can get the critical number of people vaccinated and surrounded by a protective bubble of fully immunised people then hopefully the transmission rates will settle.

"As tiring as it is to work in PPE, most staff are glad that we have it because we wouldn’t want to feel that either our own health is being compromised or that we were at risk of transmitting the virus unknowingly to patients.”

Despite admissions to hospital being lower than pre-pandemic levels, many wards are still running out of beds due to social distancing rules which mean fewer patients can be accommodated at once

Despite the mounting pressures facing the NHS, Professor Jurgen Haas, head of infection medicine at Edinburgh University, said the biggest mistake would be to roll back PPE and social distancing too quickly.

“At the moment it would be really unwise if we were to lift any restrictions too quickly, and this refers also to the NHS," said Prof Haas.

"Although more and more people have been vaccinated, there is evidence that even people who have been vaccinated twice can get severe infections. We’ve already had quite a few deaths in people who have been vaccinated twice.

“If you allow easing too quickly, and it leads to an increased number of infections in hospitals, you could put the NHS in an even more difficult situation because then what is required is that all the capacity we have is focused on Covid-19, and you make the situation even worse for the other specialities.”

Prof Haas added that Scotland would have to have "considerably lower numbers" of infections before restrictions could be "cautiously" lifted.

He said: "I don’t think there is a threshold limit where we can say you can lift restrictions completely. You just have to be careful and observe the situation.

“I would expect that at least for the rest of the year, possibly even longer [NHS restrictions will remain], because we won’t get rid of the virus very quickly."

A Scottish Government spokeswoman said: “Since the start of the pandemic, we have worked hard to ensure that Infection Prevention and Control (IPC) measures in hospital and other care settings are robust.

"This includes measures such as the appropriate use of PPE, extended use of face masks and coverings, physical distancing, good ventilation, enhanced cleaning measures, systematic outbreak management, the expansion of asymptomatic staff testing and admission testing to ensure patients are placed in the appropriate pathway.

“The guidance is kept under constant review based on the latest scientific and epidemiological evidence and the Scottish Government is currently considering how we can remobilise services and delivery, whilst keeping patient safety to the forefront.”