Twenty years ago, the Department of Health responded to these changes with a National Beds Inquiry, which forecast how demand for health care would grow over the next two decades, and the implications of this for hospital beds and other services. Three scenarios were sketched out: one where acute hospital beds were actively prioritised and increased; one where community capacity was increased at the expense of hospital beds; and one where the balance between hospital and community bed numbers was maintained.
In 2000, the NHS Plan – and the record levels of investment that accompanied it – allowed the government to do two things: pull a handbrake turn on the trend of bed reductions, and to do this by increasing bed capacity in both hospital and community settings. Between 2000 and 2004, the NHS was instructed to add more than 7,000 NHS beds across hospital (Figure 1), intermediate care, and nursing and residential homes facilities. Due (in part) to these bed increases and changes to medical care (such as the expansion of day-case surgery), waiting times for hospital care were slashed.
Fast forward to the present day. Bed occupancy has steadily crept up from 83 per cent to more than 90 per cent. Demand continues to increase. Waiting lists are growing once more. Simon Stevens – who was an advisor in the Department of Health and No.10 at the time of the National Beds inquiry is now Chief Executive of NHS England and NHS Improvement and in charge of national beds policy. But 20 years after the last National Beds Inquiry, it is increasingly hard to tell what beds strategy the health and care service is pursuing. So, let’s try and decode what the strategy might be.
On the one hand, I could tell you the number of hospital beds should continue fall as the NHS plans to move care closer to home. Initial sustainability and transformation plans (STPs) also set out substantial reductions in bed numbers based on a move towards new models of care and digital technology that would help move some services off hospital wards and into patients’ own homes (although this also reflected the reality of having to produce five-year plans that reduced costs - and beds - to meet strict financial targets). Add to this plans to build new hospitals from Liverpool to Birmingham that will replace older hospital stock, but with fewer – not more – hospital beds.
But on the other hand, I could tell you that the NHS is planning to grow or at least maintain hospital bed numbers – in line with calls from membership bodies, Royal Colleges and the BMA. A new hospital building programme has been launched, and any plans to reduce bed numbers are now submitted to increased scrutiny and challenge from the national bodies. And finally, the recent NHS national planning guidance says ‘long period of reducing beds should not be expected to continue’, and expects the peak number of beds open over winter 2019/20 to stay open throughout 2020/21.
In the end, as tempting as it seems, the NHS can’t do both. The new five-year funding deal provides far less resource than the NHS Plan did 20 years ago – and you can only spend each pound once. In addition, with 100,000 staffing vacancies the NHS could not safely staff many more beds in both community and hospital settings. In short, there is simply not enough money or staff to rapidly expand bed capacity in hospital and community care.
What would make things better?
In the absence of enough funding and staff for expanding capacity in both hospital and community settings, I think three things would help.
First, a clearer statement from national leaders over their expectations for overall health and care bed capacity over the medium term, and the consequences of these choices. There is not enough hospital-bed capacity to cope with rising emergency admissions to hospital and to substantially reduce waiting lists for planned operations. But so far, the trade-off between these two demands has been handled through relatively coded technocratic planning guidance, rather than open consultation with the public. Saying beds cuts have ‘gone too far’ is a note of caution rather than a statement of intent.
Second, a strategy on bed capacity must be based around the needs of the wider health and care system, rather than the exigencies of improving urgent and emergency care performance emphasised in the recent NHS planning guidance. The hundreds of patients travelling hundreds of miles for an inpatient psychiatric bed, and the rate at which demand is outstripping capacity for bed-based intermediate care, show strategic planning is badly needed for mental health, critical care and social care bed capacity.
Third, greater clarity is needed on who’s in charge. STP leaders may have thought they would be the key decision-makers over bed numbers, but then they found they had the ‘wrong answer’ on bed numbers when their plans were ‘marked’ by NHS England and NHS Improvement. And out-of-the blue hospital building programmes driven by Number 10 do little to create a sense that there is a coherent strategic view of the bed capacity health and care services need.
All this makes it sound like it might be time for another National Beds Inquiry that makes a transparent cross-sector assessment of supply and demand until 2040, sets out a strategy and clarifies where responsibilities lie. But the world has changed in 20 years, and perhaps it is time to let some of the old ways die. There’s no need for a full-blown analytical exercise that prescribes the exact number of beds needed from Cumbria to Cornwall or for a return to the ‘theory of change’ of the New Labour years, when the Department of Health issued circulars from Richmond House and regional bodies carried out its instructions.
What the NHS needs is some clarity and consistency from national leaders on what their current strategy is, and what the consequences are. So perhaps it isn’t time for a National Beds Inquiry, it’s time for a clearer national policy decision.