13 December 2017
The pressures on healthcare services across the UK are well-documented, and there are continued discussions about what type and level of services are needed to meet that demand. Hospital in-patient services form a critical part of those services and one of the key points of the debate is about hospital beds; the number of beds, how they are used and whether there are enough to care for the increasing numbers of patients seen throughout the NHS. As winter approaches the debate about demand and service capacity becomes particularly acute.
Background – demand for health services
In Autumn 2016 the Assembly’s Health, Social Care and Sport Committee undertook an inquiry into how well prepared Welsh health and social care services were for winter 2016/17. The Committee heard evidence about rising demand on services during the winter months but also how evident those pressures were throughout the year – especially on unscheduled care services. BMA Cymru Wales noted that:
There is an ever increasing demand for health services across the NHS which is exacerbated during winter months. Demand within the health service is now so great that hospitals are full all year round, preventing the system from coping with a seasonal spike in demand.
The Welsh Ambulance Services NHS Trust noted the additional pressures of winter but also stressed that ‘What has become apparent more recently is that system pressures now persist across the year to a greater or lesser extent’. For their part, the Welsh NHS Confederation stated that this picture is not confined to Wales but ‘recognised throughout the UK as a year round reality’; a 2016 report from the House of Commons Health Committee on winter pressures and research by the Kings Fund supports this view.
Similarly, the Welsh Government report Winter 2016/17 – An evaluation of the resilience of health and care services (2017) reported that in Wales, hospital admissions from major emergency departments have increased by approximately 7% since 2011-12, with an additional 13,203 patients admitted to a hospital bed in 2016-17 compared with 2015-16.
Understanding Hospital bed capacity
The available evidence demonstrates clearly the reductions in hospital bed numbers across the NHS. The BMA has published reports showing reductions in hospital in-patient capacity in all four countries in the UK since 2010-11. Work undertaken by the Kings Fund and NHS data for England, Scotland and Northern Ireland also evidence this trend. Published data from StatsWales shows total hospital beds in NHS Wales fell from 12,149 in 2010-11 to 10,857 in 2016-17, with an increase in the overall bed occupancy rate from 84.7% to 87.4% over the same period.
A number of professional bodies have raised concerns about this trend, including the Royal College of Surgeons, Royal College of Physicians, the Royal College of Emergency Medicine (RCEM) and BMA Cymru Wales. At the same time, these figures deserve further exploration. Whilst there has been a fall in overall bed numbers, medical innovation and changes in clinical practice have played a role, including increases in day case surgery, reduced length of stay in hospital and more community-based treatment in certain specialties such as mental health.
It may therefore be useful to look at available data for a number of specific specialties.
Table 1: Average number of daily available beds and percentage of available beds occupied; 2012-13 to 2016-17
Source: StatsWales, NHS beds summary data by year
Note: The number of average daily available beds has been rounded up to the nearest whole number
Table 1 generally shows reductions in bed numbers, but also a sustained high occupancy rate in the medical acute beds and geriatric medicine. There is debate about the safe and appropriate levels of percentage bed occupancy, with work from the Royal College of Physicians of Edinburgh supporting 85%, and other research in the BMJ suggesting 80-85%. In evidence given to the Assembly’s Health, Social Care and Sport Committee BMA Cymru Wales stated that:
Once you go above 85 per cent bed occupancy, you can predict that you can’t cope with fluctuations. You need about a 20 per cent surplus of beds to cope with the kind of fluctuations that we’re talking about. When you’ve got bed occupancies running at 86 or 87 per cent, you start getting C. diff; that delays the discharge of patients as well. (para.47)
The RCEM have also argued that high bed occupancy levels can mean that patients are placed on wards which are not specific or appropriate to their needs, resulting in slower recovery and delayed discharge from hospital. The Welsh Government report on Winter 2016-17 sets out that the optimal bed occupancy rate is 85 per cent.
Planning in-patient capacity
Welsh Government has stressed that health board three year and seasonal planning processes must ensure that capacity is aligned to predicted demand for both scheduled and unscheduled care; this would include the ability to flex capacity at times of increased demand. For winter 2016-17 NHS Wales made available additional beds to cope with higher demand, although staffing those beds posed difficulties. The Welsh Government evaluation set out that it appeared there was still insufficient capacity to meet demand and has announced plans to increase hospital and community bed capacity for winter 2017-18.
A whole systems approach
The report on 2016-17 winter preparedness from the Assembly’s Health Social Care and Sport Committee also stressed the need to see hospital beds as part of a wider service rather than in isolation. Indeed, their report specifically recommended a greater focus on the integration of health and social care and Welsh Government plans for this winter include proposals for strengthened preventative, community, primary care and social work services as well as additional support for care homes. The latter is of particular note, as the number of available care home places for older people in Wales has also fallen – by over 1,100 since 2011.
The need for a more integrated approach to the planning and delivery of health and social care services was reiterated in the Review of Health and Social Care in Wales: interim report (July 2017). The report called for new models of care in Wales which combined primary care, hospital care, and community health and social care provision. The direction of thinking is emerging clearly; hospital services and beds are a critical element of healthcare services, availability of sufficient capacity to meet demand safely is essential but in-patient services should be increasingly planned and delivered as one element of a much broader whole system of health and social care services working together.
Article by Dr Paul Worthington and Sarah Hatherley, National Assembly for Wales Research Service