This article was originally published in the Health Service Journal.

This month people living in Scotland learnt that their health secretary – who is also responsible for social care despite the lack of acknowledgment in the ministerial title – did not understand the social care sector “well enough” at the start of the pandemic. Jeane Freeman admitted the decision to discharge elderly hospital patients to care homes before a robust testing regime was in place in the early days of covid was a “mistake”.

Ms Freeman told the BBC’s Nick Robinson: “…we didn’t take the right precautions to make sure that older people leaving hospital going into care homes were as safe as they could be and that was a mistake. Now, I might argue we couldn’t do anything other than we did and all the rest of it but it still created a real problem for those older people and for the others who lived in care homes and for the staff who worked in care homes.”

Nicola Sturgeon later agreed that in hindsight, the move was indeed a mistake.

A total of 3,303 Scottish care home residents have died with covid-19 recorded on their death certificate – a third of the overall virus death toll. This compares to 30,341 deaths in care homes in England, according to ONS figures – 22 per cent of 138,911 deaths.

While there are different methods of reporting, and some research has suggested that Scottish care homes had lower levels of excess deaths from all causes, the admissions from the first minister and health secretary are undoubtedly significant, not least because – covid-19 aside – they came after years of major reforms to adult social care.

These admissions were made despite an earlier government-commissioned report from Public Health Scotland finding that there was ‘no statistical relationship’ between discharges from hospitals and care home outbreaks.

This backed up what had previously been said by SAGE; that care home outbreaks were down to a range of factors and it was difficult to pinpoint any single cause. Notably, Public Health Scotland said the most important factor behind care home outbreaks was the size of the facility in question.

"Research based on interviews with the 31 leaders of community health and social care partnerships in Scotland highlighted long-term issues when it came to patients remaining in hospital despite being medically fit to go home"

Following an intervention from the UK statistics watchdog, the report was later revised to very slightly open the door to care home discharges in fact being a cause of outbreaks – which Public Health Scotland now says “cannot be ruled out”.

All of this has refocused attention on decisions taken early in the pandemic, when often older patients were discharged from hospital to the community and to care homes, before any testing regime was in place. The number of patients whose discharge was delayed plummeted from 1,627 in February to just 604 by April.

This revealed the limits of what could be done quickly – many of the discharged patients had been waiting for social care to be put in place, while the remaining patients were held up due to processes set by incapacity legislation or because they had particularly complex care needs.

Delayed discharge in the NHS probably had a higher profile in Holyrood than in Westminster – including one ill-fated promise to end the practice north of the border by 2015. So could the pandemic provide extra impetus to ‘fix’ the problem?

The push to free up hospital beds, in Scotland as in England, came from local NHS bodies but also from the top. The Scottish government asked NHS boards and health and social care partnerships to reduce delayed discharge numbers by a total of 900 over March and April. As a result, bed days lost due to unnecessary stays in hospital were down from 45,061 in May 2019 to 21,225 in May 2020.

Research based on interviews with the 31 leaders of community health and social care partnerships in Scotland highlighted long-term issues when it came to patients remaining in hospital despite being medically fit to go home, with a blame culture and a “perception of futility” building among staff trying to tackle the problem.

Local areas had different reactions to the target to reduce discharges, with some describing them as an “unnecessary additional pressure” and saying it would not have been safe to reduce delayed discharges any further.

This criticism was echoed by Professor June Andrews, a dementia expert and former Scottish chief nursing officer, who blamed “decades of running the NHS and the care sector in Scotland as if a hospital is a place of safety for an old person, which it is not, and ignoring the population profile.”

She told healthandcare.scot: “Delayed discharges should not be allowed to build up again… The NHS has at times been given an impossible job because it gives house and home to lots of people who should not be in hospital.”

It remains to be seen whether the NHS in Scotland will again be left with this “impossible job” after the pandemic.

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