Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Hospital bed numbers were inadequate before the pandemic and will continue to be so

BMJ 2021; 374 doi: (Published 14 July 2021) Cite this as: BMJ 2021;374:n1753
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

As we approach the planned end to most covid-19 restrictions in England on 19 July, our general hospitals remain under unprecedented midsummer pressures, even though admissions and beds occupied by people with covid-19 are still way below peak pandemic levels.12 Bed capacity was a glaring problem for the NHS well before covid, and even with no more surges in infections it will remain a huge limiting factor to our health system’s resilience and performance.3

Between 2010-11 and 2019-20 England’s overall number of NHS hospital beds fell by 11%, from 144 455 to 128 943. The number of available general and acute beds fell by 8%, from 110 568 to 102 194.4

Population growth, ageing, and the accompanying frailty, disability, and multiple long term conditions all drive activity and need in health and social care. Despite a pressing need to tackle health inequalities, socioeconomic deprivation, and wider determinants of preventable non-communicable disease, it’s fanciful to think that we’ll reverse the need for hospital care in the foreseeable future.567

Overnight bed occupancy was around 90% before the pandemic and exceeded that in serial pre-covid winters.8 We must be cautious in interpreting figures from the pandemic, because infection control measures and emergency discharge arrangements reduced the number of beds available, enabled faster clearance of beds, and led to elective work being cancelled and postponed so that occupancy fell below historical levels.9

In June 2021, however, emergency department attendances in England reached an all time high for that month, at over 2.1 million, with 407 000 emergency department admissions to beds (up 21% on June 2020 and 8% on June 2019), and waits for over 12 hours rose sharply.10

The NHS also faces the longest waiting list for elective appointments since 2007, of over five million people, growing by over 600 000 in the past three months.10 These waits are often for procedures requiring beds for overnight hospital stays or day case admission. Occupancy is back above 90% in many places,11 and some hospitals have declared formal capacity alerts.12

We could debate evidence about the optimal bed occupancy needed to avoid inefficiencies and overheads from empty beds and whether the 85% sometimes quoted is the right figure.13 We could discuss whether we have enough staff to look after any additional beds when we already face a workforce crisis.14

We could explore the UK’s wisdom in hosting both acute “hot” and elective “cold” care in the same facilities so that seasonal pandemics, outbreaks, and acute demand affect planned care.15 We could discuss the efficiencies of enabling a better flow of patients through beds, fewer internal delays in processes, and a greater focus on early discharge.16

We could also argue the case for more capacity in alternative services outside hospital and a greater focus on prevention. But remember that public health17 and social care budgets have suffered sustained funding cuts since 2010, and in that time the number of people receiving home support has fallen, with care home places flatlining.1819

During that period, GP numbers have remained static and district nursing numbers have fallen, all against a background of rising demand. The National Audit of Intermediate Care20 has shown that we have nowhere near enough capacity in community alternatives to hospital beds for adults recovering from acute illness or injury.

In 2017 the Nuffield Trust’s Shifting the Balance of Care report predicted that demand for hospital beds would continue to rise and argued that ambitions to shift ever more care out of hospital beds were overstated without big additional capacity in other services.21 By 2020 Nigel Edwards, the trust’s chief executive, wrote that we were still failing to learn from the kind of over-optimistic assumptions that had led to ever fewer beds in the face of rising demand.22

I’m still not convinced that politicians or national NHS leaders are listening or learning from the history of successive cuts in bed numbers.