Journal of Public Health Medicine
Vol. 14, No. 4, pp. 359-360 Printed in Great Britain
Editorial Acute medical beds. Too many or too few? efficiencies, but by the remorseless demand for beds. If fewer beds are available then working practice adjusts to reduce lengths of stay and turnover intervals. Many physicians in England, working in busy District General Hospitals, who are in the fast stream of clinical activity, now believe that they are admitting too many patients, into too few beds, for too short a time. As 80-90 per cent of all medical admissions are emergencies, the inevitable and unpredictable surges in activity often generate a domino effect: planned admissions are delayed or cancelled, ill patients lie around on stretchers in A and E departments waiting for beds to be found for them, others have to be slept out on inappropriate wards, errors of judgement are made and many of the emergency admissions have to be sent home early to inadequate domestic circumstances. Some of those discharged too early are quickly readmitted as part of the 'revolving door syndrome'. In the statistics they become 'new cases treated' - an artful deception as they are no more than 'patient episodes'. In the mean time, junior staff, supposedly in training posts, spend much of their time on duty searching and telephoning round for non-existent empty beds to accommodate their emergencies. Their 'on-the-spot' decisions to send patients home, if proved wrong later, receive little sympathy from coroners, politicians and the media. Unfortunately, it is these over-stressed hospitals with their theoretically splendid statistics which are used as examples for others. They form the 25 per cent of hospitals with the lowest lengths of stay, used by the Audit Commission to calculate a projected reduction of a third of acute medical beds.3 Today's acute admission may be tomorrow's chronic geriatric problem and, as two-thirds of all acute medical admissions are over the age of 65, provision and management for this group of patients is inextricably linked with longer-term geriatric care. When it comes to admitting the elderly sick, the problems of 'who does what' depends much on local facilities, and the zone of demarcation between general medicine and acute geriatric medicine is not necessarily critical. What is essential is that patients of all ages have access to the skills and resources of experienced teams accustomed to managing the seriously ill. However, like the general physicians the geriatricians have had their bed problems. At a time ©Oxford University Press 1992
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In the last 15 years the National Health Service has been treating more patients, in fewer hospital beds, with a faster turnover. The average length of stay for acute medical patients has fallen from 10-2 days in 1974 to 6-7 days inl988-1989,during which time the numbers of inpatients increased by 23 per cent; over this period the acute bed stock has been cut from 158000 to 123 000.' Similar changes are reported in geriatrics and in units for the younger disabled; 243000 cases treated in 1979 rose to 447000 in 1989-1990 and available beds fell from 57000 to 51 000.2 Indices such as these have been used to highlight an apparently increasingly efficient use of one of the most expensive resources of the NHS. Nevertheless, the Audit Commission's report on The use of medical beds in acute hospitals, published earlier this year, suggested that there was room for still more improvement, and drew attention to the considerable variation in the lengths of stay of patients in hospitals in different parts of the country.1 It was concluded that if some districts with slow stream activity reduced their lengths of stay to a level comparable with those in the fast stream then the current level of in-patient treatment in England could be provided with 27000 fewer beds, thus allowing a reduction of acute hospital beds by a third.1-3 Clearly, if such a substantial cut in the numbers of beds can be made without compromising the quality of health care then this is of major importance at this time of NHS reforms. The critical phrase is, of course, 'without compromising the quality of health care'. Before we accept these proposals we need to consider some of the implications in our changing patterns in hospital bed usage. Undoubtedly, many of the scientifically proven shifts in clinical practice have led to shorter lengths of stay in hospital, but running concurrently with these reductions in length of stay has been a rapidly increasing demand for beds. The soaring admission rates have been fuelled by improved therapy, advancing technology, growing public expectations and medico-legal pressures. Faced with shortages (and closures) of hospital beds, physicians have responded in the only other way open to them, by discharging patients earlier and earlier. The length of stay of their patients in hospital has been forced down, sadly, not so much by business-like
360
JOURNAL OF PUBLIC HEALTH MEDICINE At present, we have no simple indices with which to measure the quality of health care which is delivered to acute medical patients in England. There is no satisfactory evidence that high occupancy rates and rapid turnover times equate with efficiency, and hospital doctors should be cautious in accepting the recommendations of 'paper tigers' advocating reductions in beds. Such recommendations are not mandates to close beds. For junior and senior doctors working 'at the coal-face' the pressures to discharge patients to 'make' beds for new emergencies are often intense and immediate. Their clinical decisions must not be compromised by restraints of bed shortages. The medical defence organizations have reiterated this principle on many occasions, and have insisted that the provision of adequate numbers of beds is a managerial responsibility. A buffer pool of empty beds, though costly, would make work much easier for the staff but, more importantly, would offer a more relaxed and safer environment for the patients. P.J. Tophill Consultant Physician University Hospital Nottingham
References 1
2
3
Audit Commission. Lying in wail: the use of medical beds in acute hospitals. London: HMSO, 1992. Health and personal social services statistics for England. London: HMSO, 1991; 77. Smith R. Acute medical beds could be cut by 30%. Br MedJ 1992; 304: 64.
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/14/4/359/1575424 by guest on 13 January 2019
when the numbers of the very old have risen fast, available geriatric beds have fallen from 57000 in 1979 to 51000 in 1989. Nine out of ten acute admissions return to their usual place of residence, but the elderly who remain chronically ill in hospital pose expensive and complex social placement problems to their doctors, relatives and carers. For this group of patients the NHS has reneged on its responsibilities, and half of these ill and elderly patientsfinishup in Private Nursing Homes. Over the 1979-1989 period, numbers of residents in Local Authority Homes had fallen from 102 086 to 95335 and residents in Voluntary Homes had remained steady at about 25 000; the same period saw the numbers in Private Nursing Homes rising from 26095 to 111 391, a more than four-fold increase. Nevertheless, though too many patients are hustling through the acute medical wards of numerous District General Hospitals, the Audit Commission has provided unassailable evidence that in other hospitals the pace of medical patients through the wards is unnecessarily slow. Here such factors as historical over-generous provision of beds, retention of patients for teaching or research purposes, and inappropriate use of beds may all contribute to a sluggish throughput. Lengths of patient stay in hospital may be extended by such simple factors as delays in consultants' ward rounds, waits for investigations and cumbersome ambulance booking procedures for discharge. A simple but radical change for the better might be the adoption of a continuous rolling programme of work throughout weekends and bank holidays where radiology, clinical pathology, portering, physiotherapy and administration all function normally. Will the new Trust Hospitals be bold enough to take this on?
Vol. 14, No. 4, pp. 359-360 Printed in Great Britain
Editorial Acute medical beds. Too many or too few? efficiencies, but by the remorseless demand for beds. If fewer beds are available then working practice adjusts to reduce lengths of stay and turnover intervals. Many physicians in England, working in busy District General Hospitals, who are in the fast stream of clinical activity, now believe that they are admitting too many patients, into too few beds, for too short a time. As 80-90 per cent of all medical admissions are emergencies, the inevitable and unpredictable surges in activity often generate a domino effect: planned admissions are delayed or cancelled, ill patients lie around on stretchers in A and E departments waiting for beds to be found for them, others have to be slept out on inappropriate wards, errors of judgement are made and many of the emergency admissions have to be sent home early to inadequate domestic circumstances. Some of those discharged too early are quickly readmitted as part of the 'revolving door syndrome'. In the statistics they become 'new cases treated' - an artful deception as they are no more than 'patient episodes'. In the mean time, junior staff, supposedly in training posts, spend much of their time on duty searching and telephoning round for non-existent empty beds to accommodate their emergencies. Their 'on-the-spot' decisions to send patients home, if proved wrong later, receive little sympathy from coroners, politicians and the media. Unfortunately, it is these over-stressed hospitals with their theoretically splendid statistics which are used as examples for others. They form the 25 per cent of hospitals with the lowest lengths of stay, used by the Audit Commission to calculate a projected reduction of a third of acute medical beds.3 Today's acute admission may be tomorrow's chronic geriatric problem and, as two-thirds of all acute medical admissions are over the age of 65, provision and management for this group of patients is inextricably linked with longer-term geriatric care. When it comes to admitting the elderly sick, the problems of 'who does what' depends much on local facilities, and the zone of demarcation between general medicine and acute geriatric medicine is not necessarily critical. What is essential is that patients of all ages have access to the skills and resources of experienced teams accustomed to managing the seriously ill. However, like the general physicians the geriatricians have had their bed problems. At a time ©Oxford University Press 1992
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/14/4/359/1575424 by guest on 13 January 2019
In the last 15 years the National Health Service has been treating more patients, in fewer hospital beds, with a faster turnover. The average length of stay for acute medical patients has fallen from 10-2 days in 1974 to 6-7 days inl988-1989,during which time the numbers of inpatients increased by 23 per cent; over this period the acute bed stock has been cut from 158000 to 123 000.' Similar changes are reported in geriatrics and in units for the younger disabled; 243000 cases treated in 1979 rose to 447000 in 1989-1990 and available beds fell from 57000 to 51 000.2 Indices such as these have been used to highlight an apparently increasingly efficient use of one of the most expensive resources of the NHS. Nevertheless, the Audit Commission's report on The use of medical beds in acute hospitals, published earlier this year, suggested that there was room for still more improvement, and drew attention to the considerable variation in the lengths of stay of patients in hospitals in different parts of the country.1 It was concluded that if some districts with slow stream activity reduced their lengths of stay to a level comparable with those in the fast stream then the current level of in-patient treatment in England could be provided with 27000 fewer beds, thus allowing a reduction of acute hospital beds by a third.1-3 Clearly, if such a substantial cut in the numbers of beds can be made without compromising the quality of health care then this is of major importance at this time of NHS reforms. The critical phrase is, of course, 'without compromising the quality of health care'. Before we accept these proposals we need to consider some of the implications in our changing patterns in hospital bed usage. Undoubtedly, many of the scientifically proven shifts in clinical practice have led to shorter lengths of stay in hospital, but running concurrently with these reductions in length of stay has been a rapidly increasing demand for beds. The soaring admission rates have been fuelled by improved therapy, advancing technology, growing public expectations and medico-legal pressures. Faced with shortages (and closures) of hospital beds, physicians have responded in the only other way open to them, by discharging patients earlier and earlier. The length of stay of their patients in hospital has been forced down, sadly, not so much by business-like
360
JOURNAL OF PUBLIC HEALTH MEDICINE At present, we have no simple indices with which to measure the quality of health care which is delivered to acute medical patients in England. There is no satisfactory evidence that high occupancy rates and rapid turnover times equate with efficiency, and hospital doctors should be cautious in accepting the recommendations of 'paper tigers' advocating reductions in beds. Such recommendations are not mandates to close beds. For junior and senior doctors working 'at the coal-face' the pressures to discharge patients to 'make' beds for new emergencies are often intense and immediate. Their clinical decisions must not be compromised by restraints of bed shortages. The medical defence organizations have reiterated this principle on many occasions, and have insisted that the provision of adequate numbers of beds is a managerial responsibility. A buffer pool of empty beds, though costly, would make work much easier for the staff but, more importantly, would offer a more relaxed and safer environment for the patients. P.J. Tophill Consultant Physician University Hospital Nottingham
References 1
2
3
Audit Commission. Lying in wail: the use of medical beds in acute hospitals. London: HMSO, 1992. Health and personal social services statistics for England. London: HMSO, 1991; 77. Smith R. Acute medical beds could be cut by 30%. Br MedJ 1992; 304: 64.
Downloaded from https://academic.oup.com/jpubhealth/article-abstract/14/4/359/1575424 by guest on 13 January 2019
when the numbers of the very old have risen fast, available geriatric beds have fallen from 57000 in 1979 to 51000 in 1989. Nine out of ten acute admissions return to their usual place of residence, but the elderly who remain chronically ill in hospital pose expensive and complex social placement problems to their doctors, relatives and carers. For this group of patients the NHS has reneged on its responsibilities, and half of these ill and elderly patientsfinishup in Private Nursing Homes. Over the 1979-1989 period, numbers of residents in Local Authority Homes had fallen from 102 086 to 95335 and residents in Voluntary Homes had remained steady at about 25 000; the same period saw the numbers in Private Nursing Homes rising from 26095 to 111 391, a more than four-fold increase. Nevertheless, though too many patients are hustling through the acute medical wards of numerous District General Hospitals, the Audit Commission has provided unassailable evidence that in other hospitals the pace of medical patients through the wards is unnecessarily slow. Here such factors as historical over-generous provision of beds, retention of patients for teaching or research purposes, and inappropriate use of beds may all contribute to a sluggish throughput. Lengths of patient stay in hospital may be extended by such simple factors as delays in consultants' ward rounds, waits for investigations and cumbersome ambulance booking procedures for discharge. A simple but radical change for the better might be the adoption of a continuous rolling programme of work throughout weekends and bank holidays where radiology, clinical pathology, portering, physiotherapy and administration all function normally. Will the new Trust Hospitals be bold enough to take this on?
