In Liverpool's packed Accident and Emergency departments, there are people lying in pain on waiting room floors. Elderly patients are held for days on trolleys in busy corridors and ambulances are queuing up outside for hours.
In those same hospitals, hundreds of medically fit people are waiting to leave wards. In some cases, it will be weeks before they can move on and free up badly needed beds for those waiting in the chaotic corridors below.
The images, videos and reports coming out of the region's emergency departments paint a painful and distressing image of the crisis that is currently engulfing the National Health Service. But it is those blocked-up beds elsewhere in the buildings and the frustrating stories behind them that perhaps tell the wider story of why we are in this existential mess.
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On January 5, 2023, 220 patients across Liverpool's main Hospitals had been there for more than 21 days despite no longer meeting the criteria to reside. Just one of those patients was discharged by 5pm that day.
A further five were discharged between 5pm and midnight. A total of 214 patients remained in hospital beds despite not meeting the criteria to reside. These shocking figures are even higher for patients who have been in hospitals for a shorter amount of time.
On the same date of January 5, 364 patients remained in Liverpool's main Hospitals - including The Royal, Aintree and Broadgreen - despite not meeting the criteria to stay. Sixteen patients were discharged by 5pm, with a further 11 discharged before midnight. 337 of those patients who did not meet the criteria to remain were not discharged and remained at the hospitals. Only 7% of patients eligible to be discharged left the hospitals and freed up much needed space.
The figures are similar throughout the whole month of December and early January, with the rate of those being discharged as low as 2% on Sunday 8 January .
It’s a similar case for near-by hospital trusts. For Southport and Ormskirk Hospitals, only 7% of eligible patients were discharged on January 5, however the total number of patients who no longer met the criteria was much lower for the two hospitals.
A spokesperson for NHS Cheshire and Merseyside said that "intensive and focused work is underway with health and care partners across Cheshire and Merseyside, including those in local Government, to ensure more people who are medically-fit to leave hospital are able to be discharged."
For those waiting on trolleys in corridors, inside their cars or on the floors of A&E waiting areas, the knowledge that beds in desperately short supply are not becoming free when those in them are technically fit to leave must be hard to stomach. But the situation isn’t as simple as ensuring patients coming in and out pass one another in the revolving door. Here we take a look at the wide-ranging crisis covering all sides of the nation's healthcare system.
How the social care crisis is driving the NHS crisis in a city like Liverpool
If you speak to doctors and nurses in any crisis-hit hospital across the city - or the country - and they will point to the long-term issues with social care as a key driving factor behind the delays and lack of beds within the NHS right now.
As our data shows, there are hundreds of people in hospitals who are deemed medically fit to leave a hospital setting by clinicians, but they cannot enter a social care setting - including either home care or in a residential home setting - without a number of things happening.
Elderly and vulnerable patients will have specific needs such as around toileting or mobility and before they leave a hospital they will need a care assessment to be carried out by an overstretched number of social workers who will assess whether residential care or domiciliary care is best. The patient will then need to be assessed by a care provider to work out if they can provide the care that needs.
These assessments are taking an increasingly long time because of a lack of social workers and struggling care providers being unable to fit new plans into their existing, overstretched systems.
While wealthier people may be able to pay for their care directly, the majority of people in a city like Liverpool will need to go to the city council for support. Data released last year showed that nearly half of social care users in the city are behind on fees.
Councils will agree to pay a base level of costs, like hourly rates for care workers. The care provider then has to see if they can work with this and fit it within their tight margins, with issues like transport and travel big potential obstacles. Care providers will only bid for the care package if it can fit within their existing packages as that’s all they can afford to do.
But the rates that a cash-strapped council like Liverpool can afford to pay are so low that providers will struggle to fit new care plans in their existing frameworks.
Liverpool City Council has lost more than £500m in cuts to central government grants since 2010. In place of this dramatic loss the government has allowed local authorities to raise more in Council Tax but the difference for a poor city like Liverpool is drastic.
A 1% rise in Council Tax in Liverpool will provide just £2m income for the council, which is a drop in the ocean compared to what has been lost in central funding. This means a city with much higher social needs and pressures than others is able to raise one of the lowest amounts for social care.
This situation is only going to get worse. The council cut millions from the adult social care budget last year and further cuts are proposed in the search for £73m more in savings this time around.
With care homes specifically, the council agrees to pay a certain amount towards residential care for the majority of people who cannot pay it directly. Again the council’s rates are so low because of its financial restrictions and cuts that this means there are fewer new beds being created because care homes cannot run viable businesses. Like with homecare, the reduced supply means longer waits in hospitals for people who are medically fit to leave.
All this means that in a city like Liverpool, which has high levels of need, there are far fewer providers prepared to take people and their care plans on, far fewer care homes creating beds and spaces and far fewer care workers in the sector because of poor pay and conditions. All this means there is much less capacity in social care and more and more people waiting in hospital beds because they cannot safely leave.
'It was so frustrating'
Clare McIntyre experienced the reality of this crisis first-hand when her elderly mum Angela broke her hip. The family first witnessed the problems in emergency care as Angela waited more than six hours for an ambulance to arrive after she was injured. But after undergoing surgery at Aintree Hospital she was unable to leave for more than two months.
Clare, who is a councillor in Liverpool, explained: "I hated her being in hospital for that long, the delay was because she couldn't get into a rehabilitation facility. For older people, they can decondition and deteriorate a lot while waiting in hospitals, it can be really tough for them physically and mentally.
"She was medically fit but couldn't go home and live independently and had to wait to have those care needs assessed and the right space available.
"It was bedlam in there, she wasn't sleeping and we were all so frustrated." Eventually Angela was moved to a reablement hub which was the right social care setting for her and her condition and life improved and allowed her to move home and live independently.
Sadly Angela died later in the year but Clare said she was happy living at home in her final months, something she was only able to do because of the social care she eventually received.
A delay at every stage
This issue is obviously a huge frustration for medical staff in hospitals as well. One doctor based at Arrowe Park Hospital in Wirral explained the problems moving people on are driving the issues of admitting people in the first place.
She said: "The crisis in social care means that many medically fit patients who are unable to leave because they haven't had a care package established or a review with a social worker. This creates the bed blockage behind these enormous waits for beds for those arriving at A and E.
"It's a large problem especially on wards with an older patient group (which is most of the hospital these days really). At every step of the process, there's a long wait. The more vulnerable you are, the more you need and so the longer you wait. They are very prone to deteriorating or developing an acute illness whilst waiting too, so then the process is paused.
"Some of these patients have been here for weeks waiting. This could give us an extra ten beds just on our ward."
Good neighbours
While the waiting rooms in doctor’s surgeries may be removed from the scenes in A&E and hospital corridors, they have not been immune to the current wave of pressure. Simon Abrams, a GP in Everton, said the volume of people visiting his practice has gone up “enormously” in recent months as a result of anxieties relating to Strep A and other factors.
Simon’s perspective from primary care has an up close view of the lack of fluency between hospitals and social care. In conversations with people working at care homes, he explained how patients had died but the beds left vacant were not being filled as patients were stuck in hospitals waiting on assessments.
Simon said he has been doing all he can to avoid sending patients to overwhelmed hospitals over the last six months, providing they could get the necessary care elsewhere. He points to a good and growing number of community health programmes and initiatives that enable people to receive treatment in their homes, but he has also picked up a change in how people help one another.
He told the ECHO: “People are looking after one another more. People regularly say that they have a ‘good neighbour’. The response is becoming more grass roots.”
But Simon admits the notion of a ‘good neighbour’ isn’t always enough. The care people require will sometimes demand professional expertise that goes beyond what can and should be dealt with by generous people within a local area and often just isn't available.
'We have no reward, no acknowledgement'
For those who are professional carers, the current situation is understandably bleak, tiring and lacking in recognition. Nursing staff have been roundly applauded for taking to the picket line in recent weeks in dispute over pay and conditions, but carers are facing similarly difficult circumstances for what amounts to a fraction of the salary- with many picking up a minimum hourly wage.
The pressures of the role means the sector is struggling to recruit and retain workers, many of whom are needed for assessments and the essential care that enables people to leave hospitals. Anne, 58, who only wanted to give her first name, has been a carer for the last 40 years and specialises in support work, helping people with everything from personal care to shopping and wellbeing.
“When I started out as a carer, I felt it was a career,” Anne told the ECHO, reflecting on her four decades in the sector, “it isn’t a career any more. I’ve become disillusioned with the system.”
Anne points to general work pressures, such as providing medication and the fear of “getting it in the neck” if carers miss something. She points out that “carers are not medical professionals” but are expected to meet complex needs.
She added: “It’s a 24/7 job. Work can start at 8am and then last for 13 or 14 hour shifts. Working with these people day in day out, so you don’t want to leave them. You end up working past when you’re meant to, working on days off. There’s no break on the shifts - 12 hours is 12 hours.
“There is a pressure to work overtime, so you rarely consider what to do in time for yourself. My grandkids always tell me they’re never able to see me. Staff are often covering shifts for those with younger children, just so they can spend some proper time together.”
Anne said she often remarks how long she has left until retirement and believed few people out of the younger staff will have a career as long as hers. She added: “Pay does come into it, but we feel undervalued. Everyone looks at what goes on in hospitals, but people aren’t taking into account the work that social care does. It isn’t a career any more. Many of us are on minimum wage, not even on the living wage. We have no reward, no acknowledgement”
The reality is similar for Dave, 45, who had been a carer in Liverpool for the last 15 years. The care professional, who only wanted to give his first name, said he started to noticed a downturn in the sector around 10 years ago when austerity measures were introduced.
At that point the care provider he worked for was bought out by a larger company and from there “everything started to be stripped back” as costs, wages and staff were cut. As a result he says staffing and rotas are extremely “fragile."
He said that the profession runs on overtime work with “pressure” to pick up more hours. If one person is off sick, Dave added, the daily workload swells dramatically with little chance of finding a replacement to cover.
He told the ECHO: “Morale among workers is low. The people we support have more money than we have. When working loads of overtime and you're still skint, people stop. It’s hard to keep them in the job. The challenges are bad but you get attached to the people you support. In many ways it’s good will that keeps them in there.”
'A long term challenge that nobody has ever got to grips with'
So how do we fix the crisis in social care and start to relieve some of the enormous pressure on our hospitals? Well Tom Harrison has some simple ideas to get the ball rolling.
Tom has been Chief Executive at Local Solutions for the last two years and has worked in a number of roles at the organisation since 2007. The charity supports, represents and campaigns on behalf of thousands of care workers working across Merseyside - both paid and unpaid.
When asked about the current pressures on the sector amid the ongoing NHS crisis, he told the ECHO that “social care is a complex and long term issue”, but “not all of the solutions need to be complex and long term.” In many ways it comes down to paying staff a fair wage.
He told the ECHO: “Basically comes down to recognising that frontline staff are vulnerable in their own right. They are on in many instances minimum wage. They don't have contract security.”
“The First simple thing we need to do is to pay more to retain and recruit staff. Big challenges putting more money into frontline staffing. We're competing with retail. Hospitality, leisure.
“Truth is there's 165,000 social care vacancies which means there are people who've got unmet care needs and those care needs exacerbate health conditions and they end up in hospitalisation which is extremely expensive and we can't provide the staffing to get people out of hospital. Quite simply we can't attract or retain enough staff as a sector.”
He added: "Not having an hourly rate that's attractive when you look at the things that are required in the role [is an issue]. We work with brilliant care staff who absolutely love their role. And they try to give their very best to customers and families, but they have their own families to support and there is just not enough support in the system to retain and attract staffing."
Earlier this week the Government announced that the NHS will buy thousands of extra beds in care homes and other settings to help discharge more patients to free up hospital beds. Around £200m will be made to help at a local level and to provide space and offer further care needs.
In Tom's, the approach is “pragmatic but limited”. He said: “It has to be transformational and provide ways of making it better for people to live in their own homes. It feels like a sticking plaster solution.
“Social care is a long term challenge that nobody has ever got to grips with. It has been exacerbated by economic conditions which are magnifying the challenges. But these challenges are the same ones that have been around for a very long time.”
In the meantime, our hospitals remain under severe and unprecedented pressure. Commenting on those worrying discharge figures, a spokesperson for NHS Cheshire and Merseyside said: “Intensive and focused work is underway with health and care partners across Cheshire and Merseyside, including those in local Government, to ensure more people who are medically-fit to leave hospital are able to be discharged.
“Our priority, as always, is to ensure safe and high-quality care for people in Cheshire and Merseyside and – amid exceptionally high demand - we are working closely with NHS Trusts to ensure all possible capacity across the healthcare system is utilised.
“The public can help us by seeking help from the most appropriate health service, using NHS 111 Online for 24/7 advice about the most appropriate care for your needs and only attending A&E if seriously ill or injured. This will help keep those services free for those that need them the most.”
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