Image: Flickr/Mark Hillary
Every few months for the last ten years or so, there has been renewed debate over the numbers of hospitals and hospital beds required. How far is it possible or affordable to replace hospital beds with alternative forms of care 'in the community', or to centralise services in fewer, more specialist hospitals?
Last week’s Press Association story (picked up by the Guardian) recycled some figures on bed numbers published last year by the OECD. It raises familiar questions, and underlines the extent of confusion in measuring health services by bed numbers.
The UK had 3.0 beds per 1,000 population in 2011, the same as Ireland, making it the sixth lowest provision of the 27 countries for which there are figures, and one of the lowest in Europe.
And they are for the whole of the UK: in fact Scotland has 4.4 beds per 1,000, Wales 3.75 and Northern Ireland 3.5. These higher figures conceal a much lower 2.6 per 1,000 figure for England.
Yet there are calls for still further reduced local hospital beds and more care at home and in centralised specialist units - including from all three main parties, “think tanks” of all colours including the IPPR and the King’s Fund, as well as the RCN, a number of medical Royal Colleges and even on occasion the BMA.
Such calls usually stress the potential clinical advantages. But they often downplay the cost, reduced access and capacity that would arise from diverting caseload from busy hospitals to other already busy and congested sites - or the risks of shifting it to the home.
If - to take the approach to its logical conclusion - there were one big hospital doing all the cancer care in the South of England, it would need to be enormous, would take years to plan, be hard to access, and would cost more than any government would be prepared to pay. This might seem obvious – but does not appear to have occurred to those who propose centralisation in order to increase the provision of 24/7 consultant care, without asking how many consultants would be needed to deal with the increased volume of patients.
Campaigners fighting cost-driven plans to cut back on hospital capacity, and fed up with combating cynical and half baked arguments for what they rightly see as cuts, fear that bed numbers could be cut even further.
Even Foundation Trust Network boss Chris Hopson, who has called for more hospital “reconfiguration” warns that the figures show UK acute and mental health beds operating “near full capacity”.
But what do the figures mean? These are average figures, concealing substantial local variations within each country. The concept of the generic “hospital bed” is an artificial statistical construct. The totals include all types of beds – not just the acute beds which are generally seen as the mainstay of general hospitals treating emergencies and waiting list cases.
The totals for each country include varying proportions of mental health beds, elderly care (often long stay) beds, learning disability beds, paediatric beds and maternity beds. Some OECD countries have in the past even included what we would regard as nursing home beds.
In a few European countries there is also a greater proportion of private hospital beds. Private beds in systems that pay by the day can be markedly less efficient in discharging patients than public sector beds where there are block contracts or funding based on local population.
Some countries have been much slower than the UK to change the basis of delivering services for people with mental illness, and the numbers will be distorted as a result. Average lengths of stay for the more seriously ill mental health patients tend to be far longer than for patients in acute hospitals.
France – again partly as a result of political factors and partly because of the different health care system – began reducing numbers of acute beds much later than the UK. England has cut beds at a different rate from the devolved governments in Cardiff and Edinburgh.
Some eastern European countries, formerly controlled by the Soviet Union, have a continuing legacy of health care systems based on much bigger hospitals.
In the UK and other countries, the new techniques that have brought the spread of day surgery and dramatic reductions in length of stay after operations in the last 30 years have meant that fewer surgical beds are required. But the ageing population has increased the proportion of medical admissions, most of them emergencies. The length of stay is often longer in such cases, and discharge is often more complex because it requires systems outside the hospital to support people at home.
For the same reasons, it’s difficult to draw conclusions about “productivity” in the beds which are in use, by measuring the reduction achieved in length of stay and the numbers of patients treated per bed.
What can we conclude? Health care systems need to be seen as a whole, and bed numbers put in context. The big reductions in surgical bed numbers as a result of technical advance came in the 15 years to 1994 in England. From 1994-2008 acute bed numbers remained almost unchanged, as hospitals were reduced to the minimum level needed to deal with peaks of emergency demand.
Only since the banking crash and the Tory-led government have big cuts in “general and acute” beds resumed. We have lost 5,000 beds (5.6%) since 2010, along with more than 1500 out of 23,000 mental health beds. Average occupancy rates are all above the target of 85%, and local hospitals are often way above this average.
For anyone wanting to sell the idea of a health care system based on fewer beds the key challenge is to identify the resources and the political will to create alternative, community based services. The lack of any convincing plans has been the Achilles heel of all of the cutbacks that have triggered mass popular campaigns – and there is no sign the British public is any more willing now to relinquish its tangible health care provision in exchange for nebulous promises of future services.
The other big problem for those wanting to scale down hospital care is that there is little or no evidence that reconfiguration can provide significant cost savings.
Of course there is also another quite different motive for Tory ministers and their right wing advisors wanting to scale down provision of public sector hospital beds.
If the NHS hospitals could be reduced to the point where they are constantly filled with emergencies (which the private sector will not treat) and waiting list cases are delayed, this makes it more likely those who can afford to do so will pay privately for health insurance or private treatment.
As the same debates recur, the key as always is to read between the lines, check the context – and always be suspicious of averages.