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What’s really happening with hospital bed numbers?

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4439 (Published 27 September 2017) Cite this as: BMJ 2017;358:j4439
  1. Jennifer Richardson, features editor
  1. The BMJ
  1. jrichardson{at}bmj.com

Doctors warn that hospitals are “reaching breaking point” in response to a report that seeks to provide a better understanding of NHS bed capacity in England, writes Jennifer Richardson

“It feels really tough on the wards,” says Royal College of Physicians registrar Andrew Goddard. A report from the King’s Fund this week confirms one reason why: hospitals in England are at risk of being unable to manage the movement of patients between departments, because of a growing shortage of beds.

It is the conclusion of an analysis of NHS hospital bed figures over the past 30 years and in comparison with other EU countries. Drawing on multiple sources of data, NHS Hospital Bed Numbers: Then, Now, Next, attempts to paint a clearer picture of the national situation.

This is particularly pertinent given the sustainability and transformation partnerships (STPs) charged with overhauling care by 2020-21—as the report points out, half of the 44 STPs propose to reduce the numbers of acute beds or close emergency departments.

The number of NHS hospital beds in England has more than halved in the past three decades, the report estimates. However, it emphasises the difficulty of establishing absolute figures, thanks to differing methods of data collection: the definition of a bed is loose, with the report saying that “staffed beds is generally what is meant.” The King’s Fund clarified that the numbers cover general and acute, mental health, learning disability, maternity, and day only beds as averages of “beds available [each day] for patients to receive care that are in NHS providers.” The report urges NHS England to provide a “transparent, accurate, and comprehensive picture of bed capacity” through a national audit.

The King’s Fund points out that the reduction in bed capacity is more significant than the absolute numbers suggest; as a result of population growth, the number of beds per capita has fallen faster than absolute bed numbers. For acute beds across the UK, the number of beds per capita is less than half the average for the 15 pre-2004 EU countries. The true picture is likely to be even greater pressure on beds in England, the report says, thanks to an increasingly older population who are more likely to need them.

Exactly how many beds are needed is also far from clear. Because of the number of contributing factors, including demographics and workforce, the optimum number changes over time and location, the report says. Fewer beds does not necessarily mean a shortage, but the authors point to “extremely high levels of bed occupancy and stubbornly large numbers of delayed transfers of care” as indicators that this is increasingly the case. The report also highlights a 58% increase in NHS spending on private beds providers between 2015-16 (£241m; €274m; $326m) and 2016-17 (£381m).

One of the rationales for bed cuts is the drive to provide more care in the community—however, the report finds non-hospital services insufficient. “Intermediate care capacity is currently only enough to meet around half of demand,” it says.

Despite this, the King’s Fund identifies slack still to be tightened. This includes geographical variation in length of stay: if all hospitals could match that of the shortest, bed capacity (and money) could be saved. The report highlights several promising examples of initiatives to make better use of existing beds, including a care home initiative that reduced emergency department attendances and emergency admissions.

However, the authors say that there is a lack of time and money to allow development of new models of care to reduce demand. In addition, the report suggests that a slowing down in the reduction in bed numbers shows that much of the fat has already been cut—so further reduction is likely to be increasingly difficult. Yet some STPs propose increasing the rate of cuts.

These plans look unachievable, the King’s Fund says. Instead, “realism” is needed—and a more attainable target may be to manage increases in demand for hospital services without increasing the number of beds.

What this means in practice

“The hospital seems to be full once a week,” Andrew Goddard, registrar, Royal College of Physicians, consultant gastroenterologist, Royal Derby Hospital

In the 15 years I’ve been a consultant physician I can’t say I’ve noticed the bed numbers reducing but I’ve certainly noticed the fallout. In that time, emergency admissions have increased by 51% and bed numbers reduced by 25%. We’ve coped by working to get the average length of stay down—by about 36% in this time—but it is getting harder. Ward rounds have gone from twice weekly to daily with seven day working, and this has improved flow. It may also have damaged training, which makes me worry about our future workforce. I’ve seen the introduction of the specialty of acute medicine and ambulatory care—both great. Delayed discharges seem increasingly common, though, and while we may have changed the name from “black alert” to “full capacity plan,” the hospital seems to be totally full at least once a week, most weeks.​ Many local community hospitals have been sold off, which I’m sure hasn’t helped. In short, it feels really tough on the wards and—while I’m lucky to have fantastic colleagues who all muck in to get through the frequent bed crises—I do wonder if there is much juice left in the NHS bed orange to squeeze.​”

“We are caring for patients in corridors,” Nigel Lane, consultant in acute medicine, North Bristol NHS Trust

This report highlights what we have all been feeling on the frontline for the past few years: patients are becoming older and frailer; attendances are going up; length of stay has decreased but feels like it is plateauing for acute medical admissions; and delays in transfers of care have increased. Coupled with this is the halving of the number of NHS hospital beds in England in the past 30 years.

This has resulted in caring for patients in corridors, increased clinical risk taking with regards to acute discharges, and a feeling of impending doom among frontline staff.

These reductions in overall bed numbers and increase in occupancy rates are having a real impact on my team and the patients we see. While we will continue to try to expand the numbers of patients we see in ambulatory care, and avail ourselves of opportunities to reduce variations in care—the current feeling is that we are reaching breaking point.

As the report points out, every acute bed is “staffed”—and the staff can only achieve so much with the resources we have.

“Patients are kept for too long in hospital beds,” John Kell, head of policy, Patients Association

This report shows that, in some ways, the NHS’s ability to use its beds evermore intensively has been a success story over the past few decades—but it can’t produce benefits exponentially.

It is clear that we are not good enough at either keeping people out of hospital or getting people safely and promptly out of hospital. The solutions to these problems often go hand-in-hand with improving patient experiences: timely joint replacement surgery and well coordinated care for people with complex conditions reduces demand on hospitals precisely because they achieve better outcomes for patients.

Under-resourcing of care for people in their own homes—both social care and, increasingly, NHS continuing healthcare—is implicated heavily as a barrier to progress in this report. Without this, too many patients will be kept for too long in hospital beds when they could have been discharged.

The evidence presented here casts further doubt on the viability of some STPs to reduce hospital bed capacity significantly—and, unfortunately, for some that is key to the “sustainability” aspect of their plans. While initiatives to reduce demand on hospitals and safeguard against unsafe bed closures are welcome, perhaps we need to move away from the assumption that service transformation means reducing acute capacity significantly below current levels, and instead think about it in terms of improving patient experiences and outcomes, and avoiding a steep climb in demand for acute care.

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