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
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It is not just the numbers of four legged contraptions on which patients are put. It is also the safety of the patients.
The fact is that Her Majesty's S o S is always seeking to please the Chancellor. With decimalisation of the currency, nobody seems to remember that a Quart into a Pint pot will not go.
The Chief Executives of the bodies below the S o S are constantly wringing their hands and saying there is mo more fat left. Yet, they do not say "I resign". Instead they keep whipping their staff in to greater activity. No wonder some staff drop out (or drop dead). And no wonder patients die on trolleys.
Look back, you experts in THINK TANKS (charitable, I know). And see what has been happening to hospitals and the so-called community services.
The local hospitals have steadily disappeared. There was a time when a certain politician in power agreed that Small is Beautiful. Even then the fashion for large hospitals won - presumably because small hospitals were "wasteful of staff resources".
Local maternity units closed, ostensibly to provide safer services in large district hospitals. Hospitals, including teaching hospitals, became FOUNDATION TRUSTS. In recent years even teaching hospitals have been placed in "special measures".
"Demographic changes" . Has the Dept of Health been ignorant of the changes?
Few people want to end up in a hospital bed. Few want to see a doctor (or clincal specialist, or a physician assistant, or a nurse) , They do because they have reached the end of their tether.
There was a time when hospitals such as St Barts received help from the City. Now?
There was a time when nuns from the Irish Republic, intending to go to missions abroad, would work in NHS hospitals to learn nursing (I worked with them in the 1960s). Now?
Today the NHS is no longer a SERVICE. It is a business model.
Its soul is lost.
Competing interests: No competing interests
Reading this article on the same day as hearing the new CQC Chief Inspector of Hospitals, Professor Ted Baker, set out his stall on national radio news raises a now all-too familiar scenario of people in influential positions of power very loudly saying the wrong thing for the wrong reasons.
On the one hand King’s Fund lay out simple facts and attempt to explain them in terms of changes in NHS delivery over 30yrs, rightly questioning whether in fact the drive to replace hospital beds with other things has already gone too far. The evidence is that: emergency departments are being forced to treat patients in corridors while ambulances queue outside the door; consistent >90% average bed occupancies (acknowledged to be overerestimates of true operational capacity because these metrics are gathered at midnight, after maximal discharges have been achieved, but before the day’s emergency and elective admissions have begun); increasing waiting times for elective care; maximal use of day-bed and short-stay strategies.
On the other hand Ted Baker uses his Regulator status to victim-blame the hospitals themselves by writing to their Chief Executives with no doubt further threats of sacking if they don’t jolly well pull their A+E socks up. Does Prof Baker also think that Hospitals’ inexorable fall into deficit since 2012 (now £3.6bn) is down to ubiquitously poor management by Hospitals across the country, rather than being due to a state of year-on-year defunding of essential services in a safety-critical system?
According to Ted Baker this problem was created by the last Labour government squandering the £billions which they did in fact invest in the NHS to obviate the underfunding and record waiting times created by er, the previous Tory government.
Despite real terms cuts of 63% to the NHS per capita bedbase over the last thirty years, investment in and deployment of basic IT and community service enhancements have not kept pace, so there is no compensation for these cuts beyond shorter-stay strategies for existing bed stock, and these have been exhausted. I tend to believe that the NHS’s adaptation to the loss of nearly two-thirds of its beds - while maintaining an internationally world-leading health service - is itself evidence of huge productivity gains and is indicative of the NHS’s ready adaptation to incorporate new technology, care pathways and patterns of working according to the changing times and evidence.
Although rather thin on detail, it appears that Ted Baker invests his belief in “An NHS fit for the 21st Century” in the FYFV/STP app-driven, remote access and remote monitoring, downskilled vision of a tech-heavy health service. In this vision, increasing numbers of older people will not become acutely or terminally ill in a way which requires admission to an inexorably reducing number of hospital beds, services and staff per capita, because this will have been prevented by sheer willpower, neglect of the facts, and narrow repetition of misused research statistics. For instance, it is sheer and demonstrable nonsense to suggest that half of patients in hospital “don’t need to be there”.
One may rightly question how STPs’ claims to improve care at lower cost stack up: with further cuts to beds/services by half England’s STPs; Intermediate beds at 50% of required capacity; a cut in number of general practices from 7,500 to 1,500 “hubs”; an almost complete loss of effective district nursing services; loss of any social care entitlement for 400,000 people; relegation of urgent out-of-hours triage to a 111 callcentre; all under a cuts envelope totalling £26bn. With cuts to Local Authority budgets of 37% in real terms since 2011, it is also questionable whether the purported “integration” of health and social care is less about resolving delayed transfers of care (capacity issue) and more about moving free NHS services into the chargeable domain of means-tested Social Care services.
It is certainly not clear, from what meagre evidence there is, that “Care closer to home” - whether that is self-care, remote access, remote monitoring, or peripatetic cheaper non-medical services – does even lead to reduced demand for acute or emergency beds or lower overall costs.
Simon Stevens’s FYFV/STP model appears to have materialised in 2012, where Stevens led the steering group at the Davos World Economic Forum on Global Health Innovation. The WEF report by McKinsey sets out business opportunities for global private health corporations to further their market share and it reflects rather closely the downskilled, tech-dependent, more-for-less vision of tomorrow’s healthcare which is Stevens’s FYFV/STP.
As regulator for quality and safety, Prof Baker should now be writing to Govt on behalf of the NHS, not blaming the victims while repeating the distorted mantras of the corporate global reformers. His judgements appear to be neither independent nor to grasp the realities of the situation which the NHS faces today.
Competing interests: No competing interests
A focus on the number of available beds can be a distraction from the best way to use the beds more effectively
The King's Fund report is a useful addition to the current debate on beds in the NHS. But the problem with a focus on the number of available beds is that it distracts from thinking about how to use those beds more effectively. Or whether adding more physical beds would actually lead to significant improvement.
If we took the headlines and slogans in this debate seriously we would conclude that the NHS has been cutting beds for years (true) because of government cuts (well, the budget hasn't been cut, it just recently stopped growing and bed cuts were also happening during the Blair years when the NHS budget doubled) and this has led to catastrophic decline in emergency performance because the older population needs more beds (dubious as the population is also healthier). The headlines and many campaigners want us to conclude that we just need to open more beds and things like emergency performance would get better. Simples, as the Meerkats say.
But it isn't so simple and, even if the NHS opened more beds, things might not improve as much as expected. There are much better ways to improve the way we use beds that are too often neglected in the debate.
Our ability to think about the problems, like A&E crowding, caused by lack of beds (and, therefore, our ability to think of practical actions that might generate improvements, is greatly inhibited by the way we think about bed utilisation. It is currently at very high levels across NHS hospitals (often greater than 90% which makes finding free beds for new admissions pretty hard). But the metric we use is distractingly irrelevant and gets in the way of better thinking about how to use beds more effectively. The actual public utilisation metric is the number of occupied beds at midnight (often only measured on a single day of the week). This has, at best, a vague correlation with what hospitals actually need to know to get the best use from their beds.
To get an idea of why a focus on bed numbers isn't the most useful thing in finding ways to improve consider two hospitals. Let's keep things simple and imagine both deal only with emergencies. The first hospital has an average length of stay (LOS) of 5 days. but it has a very disciplined discharge process and all discharges happen before 12 noon. The second hospital has the same LOS but the typical discharge happens late in the afternoon. Both hospitals have the same average demand for emergency admissions. Both have the same bed occupancy at midnight of 90%.
Now consider the situation at noon in both hospitals. The need for emergency admissions peaks in the morning (often at 9 or 10am) and those patients will either wait in A&E or get admitted to a free bed. In both hospitals, about 20% of all the beds occupied at midnight will be freed up at some point in the day (a consequence of the LOS of 5 days). In the first hospital occupancy at midday will be 70% assuming no new patients have been admitted but in the second the occupancy will still be 90%. In the first hospital essentially every patient in the A&E needing an emergency bed will get one as soon as the A&E department need it. In the second some might get a bed that quickly, but many will not as there are only half as many free beds at midday as the expected number of admissions during the day (which is, on average, 20% of the total number of beds). Many patients will be stuck in the A&E for far more than 4hrs as the hospital struggles to find the free beds they need.
Both hospitals have the same LOS and the same occupancy at midnight. But one has enough free beds at midday to admit every emergency admission that day; the other spends most of the afternoon struggling to find free beds for half the patients waiting in A&E. The metrics the NHS reports are doing nothing to identify the core problem with bed availability.
On the metrics the NHS uses about beds the hospitals are indistinguishable. But one will report excellent A&E performance and the other will have many patients waiting more than 4hrs and the A&E will spend most of the day in a crowded and possibly unsafe state.
Guess which hospital is typical in the NHS? The second, not the first. Should the first thing we do be to somehow create more beds?
Both hospitals might welcome extra beds as this would help them on the days when things are busier than average. But the second hospital would need 20% more beds to achieve the same performance as the first assuming nothing else changes. But past experience would suggest that even those 20% more beds would not help as much as expected because something else would change. LOS would go up as the second hospital would feel less pressure to discharge its patients. Too often in reality discharges are driven not by the state of the patient but by the pressure to find new free beds. When there are more beds this pressure reduces and occupancy and LOS goes up.
The way hospitals use beds has an enormous effect on the number that are available at the point of the day when patients need them. If every hospital had a rigorously disciplined discharge process, the NHS would have as many free beds at the point of need as it would get if it restored every closed bed for the last 20 years (assuming nothing else changed in LOS or discharge discipline).
We are having a debate that focusses on how many beds there are as though that was the entire problem. But we are ignoring the more important issue of how beds are used. By focussing on the wrong things policy makers, the central NHS bodies that collect the statistics and campaigners are all having about as much effect on practice as a homeopathic poisoner. We need to do better if we really want to improve the performance of the system.
Competing interests: No competing interests
Humanity faces, as never before, the most rapid demographic transition in its history, accompanied by an epidemiological transition that demands attention to health in all its dimensions. Population aging, the lack of a feasible "demographic dividend" in our countries, the increase in disabilities, patients with chronic diseases, the attendance to natural disasters or epidemics, make it necessary to increase care in health institutions, which in the case of hospitals means increasing the number of beds to meet the increasing demands of attention.
Our General Hospital, a University of a province in the center of southern Cuba, which serves a population of more than 407 000 inhabitants, has maintained its care services without increasing the number of beds and with the increase of demands justified in the previous paragraph. This experience we wish to share in the prestigious BMJ publication, when reading the article: What's really happening with hospital bed numbers? by Jennifer Richardson, features editor.
The experience of not having to increase hospital beds is based on strengthening the First Level of Care in the health system, maintaining full coverage and access to services at this gateway to the system, working all health institutions in the province in network, increasing ambulatory and short-stay services (use of "light hospitals" that decongest the hospital), using "early discharge" with patient follow-up, decreasing hospital stay using clinical management as a person-centered model of care. All these processes are followed with indicators that facilitate their effectiveness and efficiency.
Respecting the main mission of hospitals, we can innovate to achieve a more efficient use of hospital beds without having to increase them to offer a quality hospital service.
1. Santos-Peña Moises, Rocha-Hernández Juan F. La calidad y seguridad del paciente. Un derecho en la salud pública cubana. México DF: CIESS. Boletín Informativo. Número 14, enero-Marzo 2016.
2. Moreno Domene, Pilar; Estévez Lucas. Joaquín; Moreno Ruiz, José Antonio: "Indicadores de Gestión Hospitalaria", Sedisa S.XXI, 2010, Nº 16.
3. Ministerio de Salud Pública. Cuba. Anuario estadístico de Salud 2016. La Habana, 2017. ISSN 1561-4425.
Competing interests: No competing interests