Last Thursday, I spoke to a hospital doctor based in north-east England working in acute medicine, a catch-all term that takes in most conditions that present as emergencies, from heart attacks to kidney failure. I was put in touch with her by EveryDoctor, the advocacy group for medical professionals set up just before the pandemic. “I’ve never seen anything like this,” she told me. “The corridors are crammed with people on trolleys, being nursed. Our A&E department is twice the size it was before the pandemic, but it’s just silted up with people who can’t get beds.”
What had tipped her hospital into crisis, she said, was a bad flu season and a sharp rise in respiratory viruses, coupled with deep systemic problems that had been festering for years. She explained her fears in the apparently unruffled tones of someone who regularly deals with matters of life and death, but what she said was full of foreboding, with a sense that a basic foundation of the social contract had fallen away. “I think most people would say that if they were really ill, when they got through the doors, they’d be as safe as they could be. It feels like that’s not the case now … There’s just too much jeopardy.”
There was one particularly telling aspect of our conversation. It regularly flipped from the state of the NHS into the equally dire condition of the adult social care administered by councils and largely delivered by private providers, and a fundamental issue that hangs over this winter: the reality of an increasingly ageing society, and how little has been done to prepare for it. Low pay, high staff turnover and ongoing austerity remain the defining features of how we deal with society’s care needs, and gaping holes in provision have one particularly tragic result: patients who ought to be discharged from hospital being stranded there. If social care was halfway adequate, moreover, many older people might not be hospitalised in the first place. Clearly, one crisis is inseparable from the other.
According to the president of Royal College of Emergency Medicine, as many as 13,000 NHS patients – who account for up to 13% of hospital beds – are “medically ready to leave hospital, but have to stay because there is nowhere else for them to go”. My doctor contact’s estimate of numbers in her hospital chimed with that figure, and she also told me that bed-blocking rooted in poor social care was currently her colleagues’ single biggest problem: “If that issue was sorted, we might be able to manage.” In human terms, moreover, the problem is tragic: “There’s a great deal of misery in people being stuck on a ward. It certainly delays their recovery. Beyond a certain point, nobody gets better in hospital.”
In recent months, she went on, it has become difficult to even get care packages for people in the advanced stages of terminal illness. “In the past, if I saw a patient who had advanced cancer and wanted to go home to die, we can get that set up. Now that often can’t happen, because the home care just isn’t there.”
Journalists and politicians in England tend to fixate on the huge care bills paid by more affluent households, and the proposed funding reforms now delayed until 2025. But what of the state of social care itself? Thanks partly to rising energy costs, record numbers of care homes are going bust. In the first three months of last year, the Care and Quality Commission reported that more than two million annual hours of home care could not be delivered because of an inadequate workforce. By the late summer, credible figures suggested that nearly 300,000 people in England were waiting for an assessment of their care needs, with 600 people a day joining waiting lists.
The backstory to all this is depressingly familiar: the reckless austerity pursued by David Cameron, George Osborne and Nick Clegg, and how it flew in the face of rising need. I first heard people in local government talking about social care cuts blocking hospital beds eight years ago. More recently, sporadic-but-inadequate pots of money have been accompanied by equally sporadic talk of reform, but no sense of anyone managing to arrest snowballing failures. Over the weekend, there was news of more emergency spending – “hundreds of millions of pounds”, said the front page of the Sunday Times – to block-buy places in care homes and free up NHS beds, on top of the £500m already allotted to a new “discharge fund”. These moves might be welcome, but there is no strategic coherence: they leave the underlying factors behind the crisis untouched.
On Sunday morning, Laura Kuenssberg asked the prime minister the right question: “Would you do a job as a care worker for £18,000 a year?” He did not answer. About 50% of people in the sector earn within 30p an hour of the minimum wage. Brexit simmers away in the background, as both one cause of the sector’s mounting labour shortages, and the trigger of more indirect effects: increased vacancies in other fields are pulling people away from care in ever-greater numbers. In 2021 the vacancy rate in adult social care was 5.9%; a year later, it reached 10%. Looking ahead, we will clearly need ever-increasing numbers of people to staff the care system, but the current number of unfilled posts in the sector stands at about 165,000.
Notwithstanding the culpability of Westminster politicians for so much of this mess, these problems run across the UK, and are now receiving different and very belated answers. In the teeth of loud opposition, the SNP government in Scotland is trying to centralise provision into a new national care service; in England, Labour offers vague talk of a countrywide system that would take shape “over several parliaments”, while Tory ministers hype up the Health and Care Act of 2022 as a historic shift in “how health and care services work together”. But there is one argument you hear time and again from social care insiders: that before we get to any big conversations about sweeping change, the urgency of our current crises needs to be eased by quickly paying people more, and putting a teetering system on a stable footing. Contrary to what we hear from both Rishi Sunak and Keir Starmer, there is no immediate way out of this mess that does not involve large amounts of money, spent year after year, and a plentiful supply of care workers.
There are two viable ways to secure those things: a growing economy that will bring in sufficient tax revenue, and a genuinely welcoming approach to people from overseas. But we are not that kind of country any more, for reasons that barely need mentioning. Encouraged by the self-same charlatans who now wail about a “broken” Britain, the vote to leave the EU among the over-65s came in at 64%. That grim irony is one more element of a winter characterised by chaos and carnage, and one symbolic image that still seems overlooked: people nearing the end of their lives, stuck on hospital wards, hanging on to a dimming hope that they may somehow make it home.
John Harris is a Guardian columnist