Hundreds of Fifers stuck in hospital as health bosses battle care at home crisis
New figures produced by Fife Council show 395 people across the Kingdom are waiting an average of 77 days for care at home packages to be agreed or reviewed.
And three quarters of those are new service users with no existing arrangements in place.
Care bosses say a lack of staff, competition from the hospitality industry and the rural nature of some Fife communities are to blame - but industry figures and politicians say that the delays herald an imminent crisis in the sector.
The issues around providing care at home in Fife - a lack of staff, competition from other sectors such as hospitality, accessing rural areas - are not new, but have been exacerbated by the coronavirus pandemic.
Fiona McKay, of Fife health and social care partnership (HSCP) - the NHS/ Fife Council joint venture drawn up to co-ordinate complimentary health and care services - is all too aware of the problems.
She told a committee meeting of Fife Council last week: "Ten weeks [waiting] is too long - we recognise that, and we've got targets to bring that down.
"But I have to say that the pressures from the hospital at the moment are significant, and we're trying to cope with discharges from hospitals.
"As we're coming out of Covid, we're seeing a higher percentage of people going into hospital who maybe felt they couldn't go in [during the pandemic]. That is impacting on what we can deliver.
"Inability for external providers to recruit is a constant pressure, as they are competing with hospitality, and [there are] rural transport issues for younger staff with the cost of travel becoming a factor.
"It's not just about money, but attracting people into care and looking at all the things that are a barrier.
"There is significant pressure on us."
HSCPs across Scotland commission private companies to provide care alongside in-house council social care. In Fife, the private agency bill amounts to £44 million.
And while Fife Council has recently embarked on a "quite successful" recruitment drive for new staff, its relatively lucrative Living Wage and better working conditions are depriving the agencies it contracts of staff.
McKay acknowledges that differences in "terms and conditions" may drive prospective carers away from private providers. But the partnership cannot do without them, as its budget only stretches so far for in-house staffing.
Care has an image problem, too.
Well-meaning ministers sought to bolster links between the NHS and councils with the creation of HSCPs in 2015 - but integration has only served to expose inequalities in wages and public perception.
Former NHS Scotland chief executive Derek Feeley, who chaired the Scottish Government's independent review of adult social care earlier this year, noted in his concluding report: "There is a deeper underlying sense that social care workers have not had parity of esteem with their NHS counterparts."
Fife councillor Margaret Kennedy, a registered nurse for over 30 years, believes more needs to be made of the "health family" that provides services in and outside of hospitals in the Kingdom.
"We talk about health and social care integration, the wider weaving from government down through all levels, but there's still I don't think resonating in the wider public that it's all part of the health family," she said.
"You might not be working in a hospital or in a GP practice or have 'nurse' in your title - but in working in social care you're still very much part of that."
The coronavirus pandemic has exposed the sector's existing flaws and multiplied their impact. Staff shortages caused by illness and self-isolation - together with a worn-out workforce taking long-overdue leave - mean people are waiting weeks for care at home.
Dr Donald Macaskill, chief executive of industry body Scottish Care, says Covid has capped off a "perfect storm" of issues.
"We are facing a recruitment crisis the likes we've never had before," he rues.
"This probably reached its peak a couple of weeks ago when there was a real shortage of staff, largely due to people being pinged and having to self-isolate. People working in care that might not have taken a break [during the peak of the Covid-19 pandemic] are taking breaks.
"Things have alleviated slightly but this has exposed a real critical issue at the heart of home care in Scotland."
Mr Macaskill says home care workers are being lured elsewhere by the promise of job stability and better wages, whether that is to public care providers, care homes, the NHS - or even further afield.
"I had a look the other day and Aldi are advertising a store manager job at £60,000 a year. Social care just can't compete with that.
"People can get more money driving a delivery van for Amazon than they can being a social worker.
"There are sector issues, issues of the pandemic and changes in the immigration system at the start of the year. Scotland has always depended on people coming from overseas to work in the NHS and in social care."
The care recruitment crisis is having a domino effect on the health service.
So-called "bed blocking", also known as delayed discharge, is at its highest levels in the Kingdom in two years, with two thirds of delays attributed to "health and social care reasons". In June, 2764 hospital bed days in Fife were lost to unnecessary hospital stays caused by a delay in arranging social care.
Delayed discharges plummeted at the start of the pandemic at the behest of ministers, who were keen to free up beds and minimise the risk of vulnerable people catching Covid-19 in hospital.
A review by Health and Social Care Scotland, the umbrella group representing all 31 HSCPs, found that this had been achieved thanks to promises of extra cash for services, the unparalleled efforts of staff during a public health crisis and a sense of urgency that permitted an "anything goes" approach.
But as Scotland moves from controlling a pandemic to recovering from one, Mid-Scotland and Fife MSP Alex Rowley says Fife's NHS and care services cannot be left to repeat the same mistakes of the past.
"We need Fife Council and the health and social care partnership to be absolutely transparent about the extent and scale of the problem," he said.
"They are buying in more and more work from agencies and staff are overworked.
"It might be cheaper to buy in work through an agency, but we need to stop seeing care as some kind of low-paid job.
"We need to overhaul the whole system. It falls far short of where it needs to be, because the private sector is paying much lower wages with much poorer terms and conditions.
Fife HSCP is working on a tool nicknamed "Uber Care" that shows which agencies provide certain types of care and where, to prevent overlap and reduce costs.
Fife HSCP's Fiona McKay says the planned National Care Service - consultation on which began last week - will use learning from the Feeley Review to promote care jobs for what they are: vocations just as important as those in the NHS, and just as deserving of good pay.
Ms McKay also says a local restructure of the HSCP will better join up home care services - and is already yielding "chinks of light".
The Scottish Government says it is well aware of the challenges facing the care sector nationally. Last year it provided NHS boards and HSCPs with a combined £1.7 billion of Covid-19 support, adding a further £380 million last month.
It also relaunched its recruitment campaign, There's More To Care Than Caring, earlier this year.
A government spokesperson said: “We understand this will be a very concerning time for people whose care support services have been affected. The care at home sector is vital to the wider health and social care system and we recognise the additional pressure NHS and social care staff are facing as they work tirelessly to respond to the pandemic whilst continuing to provide vital treatment and safe patient care.
“We are in routine contact with Boards and Health and Social Care Partnerships across Scotland about a range of issues, including data which can aid our understanding of current pressures, and help our planning ahead for example for winter pressures.
“As with other areas of Health and Social Care, the Care at Home sector is facing pressures around staff summer annual leave and staff illness – as well as an increase in care needs.
“Attracting and retaining the right people, and raising the status of social care as a profession, is key to delivering quality care.