Introduction and policy context
Interest in hospital capacity and, more specifically, the number of hospital beds is growing (Bodkin 2017; Royal College of Emergency Medicine 2017). This is, in part, due to mounting evidence that hospitals are struggling: delayed transfers of care are rising, bed-occupancy rates are above recommended levels, and A&E performance remains challenged (Murray et al 2017).
At the same time, the NHS is attempting to change how it delivers care, as set out in the NHS five year forward view (Forward View) (NHS England et al 2014). To do this, 44 geographical ‘footprints’, known as sustainability and transformation partnerships, have been established. These partnerships have been tasked with transforming how services are delivered, in line with the Forward View, as well as delivering financial balance (Alderwick et al 2016).
Changing the role of acute and community hospitals and reducing hospital use is a central theme of sustainability and transformation plans (STPs). This could include reducing hospital capacity; not increasing the number of hospital beds to meet projected increases in demand; and, in some cases, cutting bed numbers from their current level (Ham et al 2017a; Quilter-Pinner 2017; Edwards 2016).
Although the proposals set out in STPs are not yet finalised, the suggestion that some areas plan to reduce bed numbers at a time when hospitals are under strain has prompted concern. For example, the British Medical Association has raised concerns about hospital bed stock in England (and other parts of the UK) (British Medical Association 2017), and we at The King’s Fund have asked whether such plans are realistic (Ham et al 2017a).
This briefing aims to place the debate about hospital beds in a wider context by:
- presenting data on hospital beds for England over a 30-year period and, where possible, data on other categories of beds used in health care
- comparing the NHS’s bed supply with other EU-15 countries
- exploring the drivers underpinning changes observed in hospital bed numbers
- considering whether STPs’ proposed bed reductions are realistic.
Alongside analysis of a range of data sources, this briefing is informed by conversations with representatives from hospital providers. It is worth noting that for certain areas, particularly intermediate care capacity, comprehensive data on bed numbers is not available; these gaps in data clearly impede national planning and should be addressed.
The number of hospital beds in England and abroad: trends over time and drivers
Hospital beds are only one component of health care; most health care is delivered without using a hospital bed. Because beds rely on staff and associated equipment to deliver care, the term ‘beds’ usually refers to staffed beds.
The number of beds needed to provide health care effectively, and how they are used, depends on a number of interrelated factors. These can be thought of in three broad categories: underlying patient demand; national policy – including funding, workforce supply and access standards; and local circumstances – such as availability of other services and internal hospital processes (see Figure 1). The population, its demographic shape, and patient behaviours determine demand. National policy shapes how this demand is met, and local circumstances are crucial in determining how demand is managed at local level.
The interplay of these factors changes over time and varies across the country. Consequently, the number of beds that the health service needs to maintain to deliver an optimal service changes over time.
NHS hospital beds in England
This briefing uses 1987/8 as the starting point for its analysis. However, the number of NHS beds had been falling for some time before this. In 1974 the health service maintained almost 400,000 beds (Macfarlane et al 2005, p 264); by 1979/80 the number had dropped to around 350,000 (Appleby 2013).
Between 1987/8 and 2016/17, the total number of NHS hospital beds fell by approximately 52.4 per cent – from 299,364 to 142,568 (see Figure 2).1 Within this total number, there are different categories of bed across which the scale of change has varied considerably.
The number of overnight general and acute beds has fallen by 43.4 per cent between 1987/8 and 2016/17 – from around 180,889 to 102,269. However, within this category beds for the long-term care of older people fell more substantially.2 Between 1987/8 and 2009/10 – when beds for older people were recorded separately – numbers fell 60.8 per cent, from more than 53,000 to slightly less than 20,900. The number of acute beds reduced by only 21 per cent over the same period.
The largest percentage falls have occurred in overnight mental health and learning disability beds, which fell by 72.1 and 96.4 per cent respectively between 1987/8 and 2016/17. This was underpinned by a policy shift to providing care for people with mental health problems and learning disabilities in the community rather than in institutional settings (see Reducing reliance on hospital care.). The number of maternity beds has fallen by around 51 per cent over the same period, mainly as a result of changes in length of stay.
In contrast to other categories, the number of day-only beds has grown by more than 520 per cent, from around 2,000 in 1987/8 to 12,463 in 2016/17, reflecting the rise in day-case surgery (see Patients spending less time in hospital).
These changes have reshaped the NHS’s bed stock, with general and acute beds making up an increasing share of the total. In 1987/8 60.4 per cent of the total stock was general and acute beds; by 2016/17 they made up 71.8 per cent of the total. Day-only beds have also grown as a proportion of the total from less than 1 per cent in 1987/8 to around 8.7 per cent in 2016/17 (see Figures 2 and 3).
- 1. Hospital beds are recorded in the national dataset on the basis of average numbers available each day. From 1987/8 to 2009/10 they were reported as annual figures. From 2010/11 onwards they have been reported in quarters; for these years we have calculated annual figures using unweighted averages of the quarterly data.
- 2. These beds have been referred to in official publications as geriatric beds.
The rate of change in bed numbers has slowed over time (see Figure 4). Between 1987/8 and 1991/2 total bed numbers fell by around 17.8 per cent, whereas between 2012/13 and 2016/17 they fell by only 4.0 per cent. Similarly, reductions in the number of general and acute beds have slowed: from around 13.1 per cent between 1987/8 and 1991/92 to 2.3 per cent between 2012/13 and 2016/17.
Over the past 30 years the most substantial falls in bed numbers have been in mental health and learning disability sectors and in long-term beds for older people as a result of changes in the way that care is provided. Consequently, acute beds now make up the bulk of total bed stock. Historically, reductions in the number of acute beds have been more modest than in other categories. In addition, the needs of patients occupying acute beds have changed over time, with a greater proportion requiring medical care rather than surgical interventions. These factors suggest it will be more difficult to maintain the long-term trajectory of reductions in the number of beds.
As bed numbers have fallen, England’s population has grown, from around 47.3 million in 1987 to approximately 55.2 million in 2016 (Office for National Statistics 2017a). As a result, the number of beds per capita has fallen faster than the absolute reduction in number of beds. The number of older people in England – who are more likely to access health care – has also increased: between 1987 and 2016 the estimated population of England aged 65 and over increased by around 33.6 per cent (Office for National Statistics 2017b).
- Critical care beds
The NHS maintains critical care beds for patients who are seriously ill and require constant support. These are measured on a different basis to other beds described in this section.1 Unlike most other categories of hospital bed, the total number of critical care beds has increased in recent years. In 2011/12 there were around 5,400 critical care beds, by 2016/17 this had risen to 5,912 – an increase of around 9.5 per cent (NHS England 2017b).2 Of these, around 68 per cent are for use by adults and the remainder for children and infants.
A recent government review of critical care services showed substantial variation in the number of critical care beds maintained per 100,000 of population across advanced health systems (Monitor 2014, p 17). In a comparison of eight advanced European systems, the UK was shown to maintain the joint second-lowest number of critical care beds relative to the population (Bittner et al 2013).3
- 1. National data on numbers of critical care beds is recorded via a monthly snapshot rather than by averaging the number of daily available beds.
- 2. This count includes beds in levels 2 and 3 of critical care: known as ‘high dependency’ and ‘intensive care’ respectively.
- 3. Countries included were Germany, Ireland, UK, Netherlands, Austria, Denmark, France and Spain.
Many patients have needs that cross institutional boundaries and use a combination of services over a period of time. Other categories of health care bed, particularly intermediate care services, the independent sector and social care, therefore matter when considering decisions about hospital bed stock.
Intermediate care beds
Intermediate care services occupy an important middle ground between primary and hospital care and are targeted at patients leaving, or at risk of going into, hospital (Oliver 2013; Stevenson and Spencer 2002). They include bed-based care, reablement services and crisis response, which often provide a much-needed step-down service for older people moving between more intensive hospital care and independent living or social care. Since 2010/11 the national hospital bed dataset has not recorded numbers of intermediate care beds.
NHS Benchmarking’s 2015 National audit of intermediate care, a survey of intermediate care providers and commissioners, found that there were an estimated 14,248 intermediate care beds in England in 2015.1 The audit suggests existing capacity is sufficient to meet only around half of demand and that waiting times for patients accessing intermediate care have grown. Recently, 46 per cent of respondents to a survey of NHS trusts indicated intermediate care capacity in their area was not sufficient to meet demand (NHS Providers 2016).
Independent sector beds
The independent sector in the United Kingdom partly caters for self-paying patients and those with insurance, but it also provides some planned care for NHS patients. Historically, NHS trusts have outsourced some elective activity to independent providers to manage waiting lists, and since 2008 elective NHS patients in England have had the option of using independent sector providers that meet NHS standards and prices (Co-operation and Competition Panel 2011). In 2016/17 the Department of Health spent a total of around £9 billion on purchasing health care from independent sector providers (Department of Health 2017a, p 170).
In the absence of official data, figures from LaingBuisson, a market intelligence company, suggest that the number of acute beds in the independent sector in the UK peaked in the mid-1990s at slightly less than 11,700 and have been falling gradually since (LaingBuisson 2017b, p 27).2 Numbers fell by 6.4 per cent between 2006 and 2016, from approximately 9,500 to approximately 8,900. In 2016/17, trusts spent £381 million on outsourcing elective activity – up from £241 million the year before, indicating an upsurge in NHS use of the independent sector (NHS Improvement 2017b, p 16). The NHS also ring-fences some beds in private patient units within NHS hospitals for patients who choose private treatment; in 2016, an estimated 1,140 beds were kept for this purpose across the UK.3
Social care provides support to people with needs ranging from disability to long-term illness and plays a key role in care provided outside the NHS, particularly for older people. England-only data is not available for social care beds, but UK figures from LaingBuisson suggest that as the NHS has reduced the number of beds it has for the long-term care of older people, the number of social care beds has grown (LaingBuisson 2017a). Estimates suggest that in 1988 there were slightly fewer than 363,000 social care beds – residential and nursing – in the UK. Bed numbers peaked at more than 525,000 in the mid-1990s before beginning to fall. Numbers started to increase again in 2010, but at a relatively modest pace; by 2016 the number of social care beds had risen to around 458,000 (LaingBuisson 2017a, pp 15–6) – an increase of 26.2 per cent on 1988 figures.
- 1. This was based on extrapolating from survey responses from 61 CCGs and 46 local authorities that indicated they commissioned an average of 25.6 intermediate care beds per 100,000 of weighted population (NHS Benchmarking 2015).
- 2. The independent sector also provides mental health care; LaingBuisson estimates there were slightly less than 10,100 mental health beds in the independent sector in the UK in 2016.
- 3. Beds in private patient units are not included in the national dataset of hospital beds.
- National Beds Inquiry
The National Beds Inquiry took place in 2000 in response to concerns about waiting times, winter pressures and the long-term decline in bed numbers (Department of Health 2000a). It covered critical, acute and community services, and the findings went on to inform the 2000 NHS Plan (Department of Health 2000b).
The inquiry concluded that further reductions in the number of acute beds should be contingent on developing alternative community-based services (Department of Health 2001). Furthermore, with a view to improving access to care and providing care closer to home, the NHS Plan set ambitions to add around 2,100 general and acute beds, 5,000 intermediate care beds and 1,700 non-residential intermediate care beds and to increase critical care bed capacity by 30 per cent by 2004.
In the years that followed, the long-term trend of falling hospital bed numbers slowed. Between 2000/1 and 2003/4 the total number of hospital beds fell by less than 1 per cent and the number of overnight general and acute beds increased by around 1,450. Contemporaneous analyses suggest the number of intermediate care beds increased by around 4,450 in the years after the Inquiry (Macfarlane et al 2005).
How does the number of hospital beds in the United Kingdom compare to other countries?
International comparisons in health care are rarely straightforward (Papanicolas and Jha 2017). In relation to bed numbers, differences in how countries organise health care make direct comparisons difficult. OECD data shows that while there is substantial variation in the number of acute hospital beds per 1,000 inhabitants across EU-15 countries, numbers have been falling in all systems in recent years (see Figure 5).
It is also clear that the UK has fewer acute hospital beds per 1,000 inhabitants than other advanced health systems. In 2014 the UK had around 2.3 acute beds per 1,000 inhabitants, compared to the EU-15 average of 3.7 acute beds per 1,000 (among those for which data is available).
Explaining decreases in the number of hospital beds
A number of factors have contributed to the long-term trend of falling hospital bed numbers. However, it is not clear whether these can be relied on to enable further reductions.
Patients spending less time in hospital
The evolution of medical care – advances in anaesthetic and surgical techniques, pain control and changes to how recovery is managed – means that an increasing number of patients spend less time in hospital now than they would have done in the past (Alderwick et al 2015).
Average length of stay in an NHS hospital has fallen by more than 40 per cent from 8.4 days in 1998/9 to 4.9 in 2015/16 (see Figure 6). The increase in the number of patients with very short lengths of stay, particularly those admitted as emergencies, has contributed to this reduction (Poteliakhoff and Thompson 2011, p3). While reductions in average length of stay have slowed in recent years, the trend has helped the NHS treat increasing numbers of people each year (see Figure 7) with a falling number of overnight general and acute beds (see Figure 8).
Alongside reductions in the average length of stay, and clinical improvements enable many patients who once would have stayed in hospital overnight to undergo day surgery (Castoro et al 2007). For example, the proportion of elective cataract surgery conducted as day surgery has grown from 62 per cent in 1996/7 to 98 per cent in 2013/14 (Alderwick et al 2015). Technical progress has also extended the range of interventions suitable for day surgery, for example, in ear, nose and throat surgery. National policy has encouraged this trend since work by the Audit Commission in the early 1990s highlighted the potential benefits of day surgery for the NHS and patients (Audit Commission 1990). This has helped the NHS to increase of the number of patients treated without needing to increase the number of beds.
Increasing day-case activity can improve productivity, but it raises questions about maintaining reductions in average length of stay. Day-case activity is not included in calculations of average length of stay, so if more of the large number of patients who are currently classed as short-stay patients were treated as day cases this would make future reductions in the average more difficult to achieve (NHS Digital 2016, p 9).
Reducing reliance on hospital care
In recent decades policy-makers have sought to reduce the NHS’s reliance on hospitals and bed-based care. A key example of this is mental health provision. Since the late 1950s there has been a move away from hospitalising people with mental health problems wherever possible, and instead to provide care through multidisciplinary teams based in the community while people live in their own homes (Gilburt et al 2014). Large-scale closures of inpatient mental health beds followed in the mid- to late-1980s. Health systems in northern and western Europe and the United States took similar approaches (Smith et al 2015).
For other areas of health care, a combination of factors has encouraged policy-makers to find new ways of meeting demand that rely less on hospitals. The cost of hospital care has played a part in this (Lagnasnerie et al 2015), as has growing recognition of supply-induced demand for hospital care (Taroni 2001; Roemer 1961). Although the evidence on the cost savings of shifting the location of care is mixed (Imison et al 2017), strengthening provision of care outside hospital has long been justified on the grounds that early intervention and support can help people to avoid costly hospital care (Edwards 2014).
Current pressures on hospital beds
The way hospital beds are used has evolved over time. In particular, occupancy rates have increased in recent years (see box below). In England, data on overnight hospital bed occupancy is available from 2010/11 and has risen from an average of 87.1 per cent in 2010/11 to 90.3 per cent in 2016/17 (based on unweighted averages of quarterly occupancy rates) (see Figure 9). Between January and March of 2017, it reached 91.4 per cent – the highest recorded for any quarter.
The true level is even higher than these figures suggest. Occupancy of overnight hospital beds is recorded at midnight; beds from which a patient has been discharged before midnight are recorded as unoccupied. Allowing for the fact that more than one patient can use a bed in a day, the Royal College of Emergency Medicine recently claimed that daytime occupancy rates for general and acute beds frequently exceed 100 per cent (Royal College of Emergency Medicine 2016, p 3).
Similarly, official occupancy figures do not reflect the true picture during winter months, when more people tend to be admitted from A&E attendances, particularly as a result of respiratory problems (NHS England 2013), and delays in discharging patients are particularly challenging. From late December to early March 2017 national occupancy of overnight general and acute beds was consistently above 90 per cent and regularly exceeded 95 per cent. In response, trusts opened large numbers of winter escalation beds – peaking at slightly more than 5,000 extra beds on two days in early January (NHS England 2017f).
- Bed-occupancy rate
High levels of occupancy can make it difficult to manage patient flow through the hospital (National Audit Office 2013), with consequences for operational performance because it becomes difficult to find beds for patients, for example, those who need to be admitted from A&E departments (Monitor 2015). A relationship between high bed-occupancy levels and increased infection rates has also been identified (Kaier et al 2010).
There is ongoing debate about the optimum level of bed occupancy. Chris Hopson, Chief Executive of NHS Providers, and Clare Marx, then President of the Royal College of Surgeons, for example, recently argued that occupancy should not exceed 85 per cent (Hopson and Marx 2017). Others, however, argue that an 85 per cent occupancy target is an ‘oversimplification’ (Bain et al 2010). A recent report from NHS England and NHS Improvement indicated trusts should avoid occupancy exceeding 92 per cent in order to maintain patient flow (NHS Improvement and NHS England 2017, p 19). However, it is not clear why they settled on that figure.
In recent months one factor contributing to rising occupancy rates has been hospitals finding it difficult to discharge patients. The number of delayed discharges, or delayed transfers of care, has risen substantially since 2014/15; in March 2017 more than 199,000 bed days were used by patients who could have been discharged (see Figure 10). This has a negative impact on patients’ care and poses operational challenges for providers.
The number of beds occupied by patients whose discharge has been delayed is not huge compared to the total bed stock; in March 2017, for example, around 6,400 beds – less than 5 per cent of the total available – were being used by patients whose discharge had been delayed. Nevertheless, delayed discharges can exacerbate operational challenges; for example, reducing the number of beds available for patients who need admission can affect performance against key waiting time standards including A&E and elective care.
Moreover, because of the very specific definition of the term delayed transfer of care, the number of patients officially recorded as having been delayed is only a sub-set of patients who could receive care elsewhere. The National Audit Office estimated that the number of older patients in hospital who are no longer benefiting from hospital treatment, but could receive the care they need in their own homes or in residential care, is around 2.7 times the delayed transfers of care figure (National Audit Office 2016). Others have highlighted even larger discrepancies in the number of patients who could be treated elsewhere and official estimates of patients whose discharge has been delayed (Edwards 2017a).
Getting greater value from beds: opportunities, initiatives and outlook
Despite impressive reductions in the average length of stay and the number of acute beds in the NHS over the past 30 years, wide variations remain both across and within different parts of the country that cannot fully be explained by differences in population need, case-mix or patient preference (see box below). Tackling some of this variation would not only free up beds but also improve outcomes for patients.
- Examples of variation
- Average length of stay for children with asthma varies from 0.8 to 2.0 days, a 2.4-fold variation among CCGs in England1 (Right Care 2016, p 218).
- The rate of emergency admission to hospital for people aged 75 years and over who remain in hospital for less than 24 hours varies 4.2-fold from 2,260 to 9,536 per 100,000 of population (Right Care 2016, p 174).
- Average length of stay for patients after a colorectal cancer resection is slightly more than 10 days. If all hospitals could match the length of stay (five and a half days) of the best hospitals in the UK, 84,000 bed days would be saved, along with £23.6 million (Abercrombie 2017).
- Rates of day-case surgery vary, even for procedures where there is clinical agreement about its use. For example, according to the British Association of Day Surgery, at least 20 per cent of anti-reflux surgery should be possible as a day case. Yet most trusts do not currently offer this surgery on a day-case basis, despite data suggesting it improves patient experience and cost efficiency, with no detrimental impact on outcomes (Abercrombie 2017).
- 1. The seven CCGs with the highest rates and the seven CCGs with the lowest rates have been excluded from these figures.
There is also evidence that some demand currently being met by hospitals could be dealt with more appropriately in other settings. For example, around one in five emergency admissions to hospital are thought to be avoidable with better and more co-ordinated care management in the community (Blunt 2013). And once people are admitted to hospital, they often stay there longer than is medically necessary due to problems sorting out arrangements for their onwards care (see Current pressures on hospital beds).
As The King’s Fund and others have highlighted, a relatively small number of mostly older patients who remain in hospital for a long time use a large proportion of bed days (Edwards 2017b; Poteliakhoff and Thompson 2011). For example, in acute and geriatric specialties the 9 per cent of patients who stay in hospital for more than seven days use more than 72 per cent of total bed days (Edwards 2017b).
There is wide variation in how older patients are cared for in different parts of the country. Previous research showed greater than two-fold variation in needs-weighted admissions per person and emergency length of stay for people over the age of 65 between different areas, with consequences for hospital bed use. Those areas that had more integrated services for older people showed lower rates of hospital bed use (Imison et al 2012, p 3). So, while the challenges associated with caring for these patients – who often have complex needs – are real, there is an opportunity for the system to learn from the best-performing areas to identify more appropriate care settings.
NHS initiatives to make optimal use of beds
The NHS has put in place a range of initiatives – targeted at reducing variation, improving patient flow and moderating demand – to try to maximise the value it gets out of existing bed stock.
- Getting It Right First Time (GIRFT) – a clinically led programme that seeks to improve quality and reduce cost in the delivery of hospital care by identifying and then tackling unwarranted variations in services and practices.
- RightCare – a national NHS England-supported programme aimed at reducing unwarranted variation in commissioning.
Improving patient flow
- A government target for the NHS and local authorities to reduce delayed transfers of care to no more than 3.5 per cent of all hospital beds by September 2017 with a view to freeing up 2,500–3,000 beds (Department of Health 2017b).
- Introduction of primary care streaming in A&E departments, aimed at enabling A&E staff to focus on patients with the most complex conditions, thus reducing wait times and improving patient flow.
- The Emergency Care Improvement Programme – a national scheme providing support to local areas to improve the performance of emergency care.
- Flow management tools – NHS Improvement has published a number of tools to assist trusts in managing patient flow, eg, the SAFER bundle (NHS Improvement 2014) and the recent good practice guide (NHS Improvement 2017a).
- Earlier planning for winter – in 2017/18, formal winter planning began in July, considerably earlier than in previous years and included guidance that trusts should plan for bed occupancy of 92 per cent or less (NHS Improvement and NHS England 2017, p 5).
The NHS has been testing new models of care in 50 vanguard areas across England. Central to the vanguards programme is moderating rising demand for hospital care by focusing on prevention, early intervention, admission avoidance and support for people to remain independent in their own homes.
Alongside these initiatives, national NHS bodies are increasing their oversight of bed stock: NHS England is currently carrying out a national audit of bed stock (Illman 2017) and in April 2017, NHS England Chief Executive Simon Stevens introduced a new test requiring local NHS organisations to demonstrate that ‘significant’ proposed bed closures meet one of three new conditions, one of these being that sufficient alternative provision, such as increased GP or community services, is put in place alongside or ahead of changes (NHS England 2017d). National NHS bodies have also advised trusts to reduce bed-occupancy levels in preparation for winter.
STP proposals to reduce bed numbers
The 44 sustainability and transformation partnerships across England are tasked with enacting national initiatives at a local level to transform care in line with the Forward View by 2020/21.
The emphasis placed on financial balance as a key objective for these partnerships has increased in recent months (Ham et al 2017a). While the scope of sustainability and transformation plans (STPs) is broad – ranging from prevention and primary care to specialised services in hospitals – all STPs include proposals to change the role of acute hospitals, with some seeking to centralise services on to fewer sites and others planning to reduce bed numbers. According to a recent analysis, 50 per cent of STPs include proposals to reduce acute bed numbers or the number of A&E departments (Boyle et al 2017).
It is difficult to assess the net effect of all 44 STPs’ proposals on national bed stock. For example, plans include varying levels of detail, with some using activity rather than beds as the unit of planning, while others quantify bed reductions in relation to a forecast number of beds in 2020/21 rather than current levels. There is also some uncertainty about whether proposals will be implemented as they were written in the original plans, particularly in light of NHS England’s new tests for bed reductions.
Using a number of strategies – preventing ill health, providing more co-ordinated out-of-hospital services, intervening early and capitalising on the potential of technology – some footprints are proposing ambitious reductions in the number of hospital beds. For example, Dorset STP suggests it will need 240 fewer beds by 2020/21, Derbyshire 530 fewer, and Leicester, Leicestershire and Rutland 281 fewer. South West London’s original plan aimed to reduce inpatient bed days by 44 per cent, which would translate to 450 fewer beds (Ham et al 2017b). If implemented, some of these proposals would involve bed numbers falling faster than the national trend in recent years. This raises questions about whether the proposals will be achievable.
What next for hospital beds in England?
A number of changes to how care is delivered have resulted in the number of beds falling over the past 30 years. While many advanced health care systems have seen bed numbers fall, the NHS currently has fewer beds relative to the population than almost any other comparable health system.
A significant portion of this reduction has been due to shifts in policy that have resulted in fewer people with mental illness and learning disabilities being treated in institutional settings, with care and support now provided in the community. Alongside this, the long-term care of older people has largely moved out of acute hospitals and is now delivered in care homes, nursing homes and in their own homes. Other factors such as medical innovation, which has enabled less invasive surgery and shortened recovery time, have resulted in reduced length of stay and allowed more people to be treated within existing bed stock.
Some opportunities to deliver more value from existing bed stock remain. Focusing on variations in practice (including in average length of stay), cutting delayed transfers, preventing avoidable admissions, improving patient flow and strengthening out-of-hospital provision all offer promise, which are being realised through a range of national initiatives. Sustainability and transformation partnerships have been tasked with implementing new ways of delivering care and progressing these – and other – initiatives. In part because of demanding financial control totals, we know some STPs propose to reduce bed numbers over the coming years, and in some cases by more than the recent trend.
Early findings from some initiatives to get maximum value from hospital beds are showing promise. For example, improvements to primary hip and knee replacements through the GIRFT programme have freed up the equivalent of 50,000 bed days (Timmins 2017), while vanguard areas trialling multispecialty community providers (MCPs) and primary and acute care systems (PACS) models have seen lower per capita growth in emergency admissions than the rest of England1 (NHS England 2017e, p 31). One vanguard site trialling a more joined-up, proactive form of health care in care homes has reduced A&E attendances and emergency admissions among residents compared to a comparator group (Lloyd et al 2017).
However, realism is needed about what can be achieved. Arguably, NHS hospitals have never been under greater strain than they are today. Population growth, combined with an increasing proportion of older people more likely to need health care, is driving greater demand for NHS hospital treatment – from A&E attendances and emergency admissions to referrals, outpatient services, diagnostic tests and elective admissions (Maguire et al 2016). At the same time, the NHS is enduring a prolonged slowdown in funding. On current spending plans, the NHS budget will increase by an average of 1.1 per cent a year between 2009/10 and 2020/21, compared to a long-term average increase of nearly 4 per cent a year since the NHS was established (The King’s Fund 2017b).
This financial settlement is affecting provision across the health and care sector. Out-of- hospital services – general practice (Baird et al 2016), district nursing services (Maybin et al 2016) and mental health care (Gilburt 2015) – are all experiencing real strain. Intermediate care capacity is not able to meet demand. And social care has seen an 8 per cent real-terms cut in spending by local authorities between 2009/10 and 2015/16 (The King’s Fund 2017a). In turn, the number of people accessing publicly funded social care has fallen 26 per cent in recent years (Humphries et al 2016).
There are signs of a growing shortage of beds, as can be seen in extremely high levels of average bed occupancy and stubbornly large numbers of delayed transfers of care. There are also specific concerns about bed stock in mental health, with the Royal College of Psychiatrists warning of a ‘national crisis’ resulting in more patients needing to be sent out of area for treatment (Coggan 2017). Current levels of occupancy mean the average hospital in England is at risk of being unable to effectively manage patient flow leaving it vulnerable to fluctuations in demand.
Against this backdrop, it will be challenging to reduce the number of beds significantly. Bed occupancy cannot continue to rise indefinitely and there is only limited spare capacity, while falls in average length of stay appear to be slowing.
While new models of care have the potential to improve patient outcomes and experience, analyses of the evidence underpinning them suggests they will not necessarily reduce the need for hospital care (Imison et al 2017). Earlier work suggests that interventions intended to reduce unplanned hospital admissions often struggle to moderate demand (Purdy et al 2012). Implementation also takes time; it can take several years for new models of community-based care to develop and to start to deliver results (Bardsley et al 2013; Goodwin et al 2013; Steventon et al 2011). They also require investment – to cover the costs of staff time, programme and physical infrastructure, and double-running costs (to allow new services to be set up while still providing existing services) (Health Foundation and The King’s Fund 2015).
STPs therefore are tasked with delivering ambitious change at a time when the NHS could reasonably be described as being under unprecedented strain. Indeed, the ambitious timetable, projected pace of reduction, and a lack of investment in transformation to support double-running of services make the commitments set out in some STPs to reduce beds by 2020/21 look unrealistic. Recent announcements by NHS England hint at a recognition of the growing concerns regarding bed stock (Illman 2017; NHS England 2017d). Rather than reducing beds, managing likely future increases in demand without increasing bed numbers may be the definition of success.
- 1. Compared to national growth of 3.2 per cent from 2015, MCPs saw a 1.9 per cent increase in per capita emergency admissions and PACs achieved a 1.1 per cent growth rate.
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Average length of stay: the average amount of time in days that patients spend in hospital between admission and discharge (day case admissions are excluded from the calculation).
Bed-occupancy rate: the percentage of available beds occupied by a patient. For overnight beds occupancy is measured at midnight each day; day-only beds are recorded as occupied if at least one patient has used the bed in the past day.
Day-case surgery: surgery for which the patient is admitted to hospital, the operation is performed and the patient discharged on the same day.
Delayed transfer of care: an adult inpatient in hospital who is ready to leave to return home or move to another setting, but is prevented from doing so. There are three conditions for a patient being ready for transfer:
- a clinical decision has been made that the patient is ready for transfer
- a multidisciplinary team has decided that a patient is ready for transfer
- the patient is safe to discharge or transfer.
EU-15 countries: EU member states prior to the May 2004 expansion: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom.
Escalation beds: temporary beds opened by NHS providers during winter to provide short-term capacity.
General and acute beds: beds for patients who have been admitted from A&E or by their GP or who are recuperating after surgery. These include patients being treated by a range of specialties including general surgery, trauma and orthopaedics, cardiology and general medicine.
Supply-induced demand: demand for health care that in the absence of the provider may have gone unmet. Not necessarily inappropriate care.
- Data sources
Our key sources of data for this briefing are quarterly bed availability and occupancy data published by NHS England, and the OECD’s Health Care Resources dataset. In addition, we drew on NHS England’s monthly situation reports and winter daily situation reports.
NHS England bed availability and occupancy
As noted, there have been some changes to the definition used in NHS England’s quarterly bed availability data. Until 2009/10 the data was collected by ward type; since 2010/11 it has been counted using consultant speciality. Consequently, some types of beds, including intermediate care and community mental health, are excluded from current data. Comparisons across the period should therefore be treated as approximate. In 2015/16 mental health beds were revalidated and this led to a reduction of numbers of around 10 per cent. The data collection only includes beds at the reporting provider, not beds paid for at any other provider.
NHS England monthly situation reports
NHS providers submit monthly situation reports to NHS England. These record the number of critical care beds available and occupied. In contrast to the bed availability and occupancy data set, the monthly situation reports record the number of critical care beds via a snapshot on the last Thursday of each calendar month rather than as an average.
The authors would like to thank Julie Pearce of Dorset County Hospital NHS Foundation Trust and Matthew Bryant of Taunton and Somerset NHS Foundation Trust who participated in interviews as part of the project.
We also extend our thanks to our external reviewers Nigel Edwards, Matthew Lewis and David Oliver.
I agree with the overall statement as demonstrated repeatedly by OECD annual reports that most countries have reduced bed numbers on the back of length of stay reductions
However from2007 onwards a worrying trend has emerged,disguised by the graphical displays of reports from 209 onwards but there in the data.
The majority of countries with LoS above that of the UK continue to see annual reductions BUT significant proportion below UK' acute and average LoS across elective specialties have seen either a steadying or a slight upwards rise from 2004 onwards - all sorts of things from the co morbidity of dementia to increasing specialisation, new disease diagnosis, and just beds becoming less efficient when there are too few may contribute due to an increase in readmissions and revolving door edicine. Factor in large parts of the country where thre is no intermediate tier and massive waits for basic community services as the soft underbelly of the NHS is chopped back every year whilst social care providers are unable to recruit leaving whole parts of the UK without social care.
Speaking in week 7 of being medically fit for discharge blocking a specialist renal bed and being prepared to fully fund my own care. but no provider can take on the complexity of my home care package! 3 of the other 8 patients in my bay have the same issue of no community provision.
Is it not about time we revisited the most expensive decision ever made politically: the separation of health and social care funding mechanisms creating instant delay (delays eliminated in Scotland through the responsibility for provision being publicly managed preventing the market from determining which towns and villages get a service and the post code lottery of the private sector?)
Kevin S Riley MLS. Grad IPD. Dip. Mgt (CNAA) Solicitor
Keswick Hall Pinstock Lane Gedney PE12 0BT
30th September 2017
Dear Professor Ted Baker Chief Inspector of Hospitals.
As someone who has had experience regarding delivery of health services since 1962, I would entirely agree with your reported comments.
However, no doubt your comments will be rejected by unnamed sources at the DOH and Theresa May and Jeremy Hunt but are in fact entirely correct.
However, one aspect you did not mention and which will result in neither the Government, the DOH or even NHS England being able to achieve improvements throughout the NHS as a whole ,is the fragmentation of the NHS as a result of the Health and Social Care Act 2012.
As you will be aware the above acted removed the NHS from democratic control by transferring responsibility to the then newly created “independent” and “free from democratic control” NHS Foundation Trusts.
Each individual Trust can now make it’s own decisions about the delivery of health services and there is nothing that the Government, the DOH or NHS England can force them to deliver health services in any particular way – set attached for details..
We now have a fragmented Health Service which has resulted in a variable standard in the delivery of health services across the country far worse than the much criticised post code lottery which previously existed.
You will also know that despite the critical reports and recommendations of the CQC as to how failings should be addressed – many Chief Executives of the Trusts criticised fail to take action – perhaps the most glaring recent example being the behaviour of the former Chief Executive of the Southern Heath Service Trust – but there are many others.
Putting Trusts into special measures, only addresses the fundamental problem identified above (and as detailed on the attached) in the short term and is very costly to the taxpayer.
The above, not least because the Chief Executives and other senior “managers” of the Trusts concerned, who have failed in their management responsibilities, are allowed to retain their salary and pension entitlements and routinely are appointed to other senior posts in the now fragmented NHS - notwithstanding their identified management failures..
Therefore the problems in the delivery of health services in the NHS are far wider than you have initially identified.
I shall be obliged to hear your views.
Kevin S. Riley Solicitor
FROM Kevin S. Riley Former prosecuting Solicitor now retired from active legal practice - with thirty years’ experience of advising senior politicians ultimately responsible for the conduct of tax payer funded bodies both on policy and associated legal issues.
I was appalled to hear yet another dismissive response from the Government and the DOH concerning the dangers to patient safety as a result of the knownshortage of nurses (and indeed Doctors) at/on the front line of service delivery.
The above made even worse by the fact that Robert Francis QC identified such a shortage as the primary cause of 1200 "preventable deaths" at the two Hospitals run by the Mid Staffs NHS Foundation Trust.
As a result Robert Francis recommended that the Government/DOH set a mandatory minimum level of staffing numbers that Trusts must employ on wards and in A and E departments. ward level.
Jeremy Hunt on behalf of the Government refused to accept this recommendation and quite disgracefully, given the findings of Robert Francis, stated that thedecision on strafing numbers was "best left to the Chief Executive of each Trust to determine".
The above decision made even worse as neither the Government, the Department of Health or NHS England now have any control over how the now "independent" and "free from democratic control" NHS Trusts behave ( other than determining how much of tax payers money is given to each independent Trust each year - so any comment on this issue made by Jeremy Hunt, Theresa May or the DOH on this sue has any relevance at all - yet the BBC and the rest of the media keep quoting them as if the reverse were true..
Once that money (or any extra money) is given none of the above can actually control how that money (or extra money) is actually spent.
The above as a result of the contents of the Health and Social Care Act 2012.
The current position is made even more appalling as
a) more and more independent NHS Trusts have been found to have allowed "preventable deaths" to occur (identifed as such by the CQC) many due to a shortage of staff and all that has happened (if anything at all) is they have been prosecuted by the Health and Safety executive, and
b) he above resulting in a massive fine which is not paid by the senior managers responsible for creating and or allowing the conditions which directly led to the preventable death or deaths but by the tax payer.
The relevance of the Criminal Law to Improving Patient Safety.
In every other environment where senior managers have been found to have allowed "preventable" deaths to occur, the individual manager responsible has been prosecuted for manslaughter due to a breach of his or "duty of care" to the individual who had died.
That "duty of care" applies even more importantly to the Chief Executives and other senior managers in the now "independent and free from Democratic control" NHS Trusts and a perceived shortage of funds is no defence to such a charge.
Yet despite literally thousands of preventable detahs having been identified both by Robert Francis QC and the CQC individual Trusts (and even where negligence of individuals has been identified by a Coroner) not one Chief executive or senior manager in the NHS as a whole has ever been prosecuted.
The relevance of the above is that it would only require one Chief Executive or other senior manager to be prosecuted for this offence for this to immediately result in improvement to patient safety throughout the NHS as a whole .
The only way you and/or the BMA (or jointly) can do anything that will change the situation is by exposing the position by way of a Judicial Review.
More information (FOC!!) available on request.
Kevin S. Riley Solicitor