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NEWS & COMMENT

London Perspective Too many medical beds? One thing is certain about the Audit Commission’s latest report on the health service: it is not going to be debated on the hustings. The last thing any of the three main political parties wants in the run-up to the election is a serious debate about the number of medical beds needed in NHS hospitals--especially after the Audit Commission has concluded, in its latest report on the health service, that the number could be cut by a third (27 000) if all health authorities used their beds as effectively as the most efficient 25%. The health debate will now most likely turn to: who shut down more beds and closed more hospitals, on the implicit assumption that more is better. Like most developed states, Britain has been steadily reducing the number of hospital beds, and the trend has continued under both Labour and Conservative administrations. Between 1974 and 1988 the number of beds fell by 22%, yet the number of patients treated per year increased in this period, also by 22%. This rise has been achieved through shorter average lengths of stay (6-7 days instead of 10-2) and a reduction in the time beds remain empty between patients (from 3-9 to 2-3 days). The number of patients treated in each acute bed has increased from 26 to 41 patients a year. The number treated in the NHS has risen from 4-1 million to 5 million. As the Audit Commission notes, "It may seem perverse to argue that a further great leap forward could be achieved without any increase in the resources devoted to patient treatment. Yet the evidence suggests this is possible". The Commission, which was set up 10 years ago to improve the efficiency and effectiveness of local government, had its remit extended to the NHS in 1990. The aim is not to save money but to release resources that can be used for other purposes.

The latest report began when Dr Jonathan Boyce, the doctor with a management degree who has been leading the study on medical beds, was scouring NHS performance indicators and came upon a startling two-fold variation in bed provision between districts-and a four-fold variation in throughput. The team decided to look at the onc-quarter of acute beds that are used for medical or acute geriatric patients to see how admission, treatment, and discharge procedures could be improved. The Commission concluded-after studying data from 135 English districts, sending detailed questionnaires to 100 hospitals, and visiting to 10 hospitals-that 41% of the variation was explained by districts’ age structure. But 59% bore no obvious relation to the needs for health care and was due to differing medical opinions and administrative practices (27%) and failure to provide the right number of beds for the district (32%). So how does this square with the clinicians’ lament about the shortage of beds? The report gives two answers. First, that the need for hospital treatment cannot be precisely defined: it points to the wide variations

in length of stay between countries and suggests that this "is most unlikely to reflect differences in disease severity". Second, it lists previous studies showing that both admissions and length of stay increase with bed availability. Its inquiries uncovered the ultimate in inappropriate treatment-a patient in Ealing who had occupied an acute bed for over 10 years, shutting off treatment to roughly 400 potential patients before the district appointed a placements officer. The report suggests that it is time to end the old approach under which management provides beds and the clinicians fill them up. Instead, the Commission wants managers to stop treating beds as units of resource by being more proactive in influencing patient flows and by adjusting the number of beds to health-care needs. It sets out a long list of recommendations but emphasises that most of the resources freed would have to be redirected to community services for the standard of care to be maintained. The study found a variety of reasons for the large number of inappropriate admissions: unclear decision procedures; misunderstood procedures; unclear clinical protocols; and inexperienced duty teams. It found a fourfold variation in the rate of emergency admission referrals by GPs, some of whom were using the procedure as the quickest means to obtain a second opinion. One hospital rejected half of all referrals; another took them all. None of the hospitals collected details about the emergencies refused, or what happened to them. One category of inappropriate admissions involved people who did not need treatment, only observation (such as head injuries or drug overdose). The Commission suggests that observation beds should be attached to accident-and-emergency departments rather than the main wards. Once through admission, there were other difficulties: unreliable information on bed availability (sometimes 5% of

patients were left overnight on trolleys); placements in inappropriate wards even when empty beds were available on appropriate wards; and inappropriate transfers between wards. Medical records were found to be riddled with inaccurancies: one survey found there was disagreement in 36% of cases between the computerised records and medical notes. More sophisticated records were equally shaky, with one survey of 26 hospitals finding 27% of the diagnostic

codings incomplete. Like a long list of

earlier inquiries, the Commission discovered many unnecessary delays in the discharge of patients. The report notes the weak scientific basis behind the widely varying lengths of stay that clinicians deem appropriate for various conditions. The absence of clinical budgets exacerbates the problem. In many instances, only consultants can authorise discharge, and typically they hold ward rounds only twice a week. The highest number of discharges are made on Fridays, a favourite ward-round day, despite the difficulties of gaining access to community care at the end of the week. The Commission notes, too, a community health council study that found half of all patients received less than 12 hours’ notice of discharge and a further third less than 3 hours. 93% of patients return to

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their usual place of residence, but the remaining 7% have a disproportionate impact on beds. About half the hospitals had no clear responsibility for finding long-term places. The Commission urges action on several fronts: better management information; more medical audit (the Health Department’s grant is for only two years); improved resource management; better administration; and earlier use of social workers, physiotherapists, and occupational therapists. Admissions would be more appropriate if not left to inexperienced junior doctors. There should be written admission procedures with a priority list. The Commission wants consultants to be more ready to delegate discharge decisions (so long as recovery is proceeding as expected) to junior doctors and senior nurses. It points to the success of placement officers (the Ealing officer not only cleared 30 beds blocked by people needing long-term residential accommodation within a year but also found places for 90 other "potential blockers"). Other proposals include targets for average lengths of stay; better monitoring of delayed discharges and identification of the causes and consequences; more elective medical work in the summer and autumn, when there is spare capacity. Implementation of the Commission’s first report, on day surgery, was helped by many other pressures for change, including the support of the Royal College of Surgeons (which ordered 16 000 copies of the report) and the availability of new technology, which so fascinates surgeons. What will happen with this report? Like all Commission studies, the team was backed by an advisory group drawn from every branch of medicine. It worked closely with the Royal College of Physicians. Yet there are differences. There is not the same enthusiasm for change among physicians and geriatricians as there was with the surgeons. There are about 2500 consultants to convince, at a time when the state of community care is still uncertain. Do not expect this latest report to generate the same pace of change as the day-surgery report.

imbalance. Present estimates are that about 800 overseastrained doctors come to Australia each year, and most enter general practice. This compares with only 600 or so local graduates who enter general practice each year. This apparent bias has been openly and frequently criticised by the Australian Medical Association during the past several years, along with criticism of the standard of training of some overseas graduates. The College is more circumspect in suggesting that "the quality of Australian medical education and training is world renowned and the College considers that opportunities ... should be available first to Australians". The wider issue has more to do with a balance between geographical areas in proportion of local graduates. Local graduates have been reluctant to practise in rural areas, whereas overseas graduates, especially those from Asian countries, have been willing to fill the gaps, and critics of moves to restrict their numbers say that rural areas will remain disadvantaged. At a political level, Medibank expenditure continues to increase rapidly. The Government sees general practice as the generator of most medical services and has for some time threatened a forced adjustment to the imbalance between the supply and demand for general-practice consultations. This latest move by the College should preclude any precipitate action by the Government for the time being. Its recommendations will soon be put to a tripartite General Practice Consultative Committee representing the College, the AMA, and the federal Department of Health, Housing, and Community Services.

Peter

Harrigan

European Community: Health policy after Maastricht

Malcolm Dean

Round the World Australia: Suggested restrictions on GP numbers and opportunities for overseas

graduates The Royal Australian College of General Practitioners has recommended reducing the total number of general practitioners in Australia by about 6000-on the basis that standards of care can be maintained with an ideal GP-topopulation ratio of 1:1500, and thus requiring about 10 000 practising GPs. However, overseas medical graduates will not be as well represented in future GP numbers if a second

proposal suggested by the College is taken up. The College has recommended that the admission of overseas-trained doctors to general practice should be limited to a maximum of 5% of the annual total number of graduates entering from Australian medical schools. Although the College wants this restriction on overseas-trained doctors to be introduced immediately, it accepts that the reduction in overall numbers of general practitioners would take "a period of time". Restricting the opportunities for overseas graduates is necessary, says the College, to redress an apparent

The highly politicised nature of the debate on the Maastricht summit last month-notably the issue of monetary union--diverted attention from important decisions in the small print of the agreement, including a bigger say for the European Community on health policy. The commitment by the twelve EC member states to "coordinate health policies and programmes in conjunction with the European Commission" got less coverage in the UK than the question of whether the Queen’s head should appear on the ecu. Moreover, the combined effect of Maastricht and the EC/EFTA agreement in October to create the European Economic Area will lead, increasingly, to health decisions being made in Brussels and Strasbourg on behalf of 376 million people living between the Algarve and the Arctic Circle. Maastricht seemed to be largely about the F (for federal) word, a brouhaha that was part constitutional debate and part semantics, given that there seem to have been twelve conflicting interpretations of the term. The H word remained largely unspoken, just as "health" appears nowhere in the formal terms of reference of the 17 members of the European Commission. Yet almost every member of that collegiate body is involved in health issues-indeed, a fragmented approach to health has caused problems for the EC, as last year when it emerged that so many departments were involved in biotechnology that a special coordination group was required. Brussels has no commissioner for health, nor even a repository of central

Too many medical beds?

170 NEWS & COMMENT London Perspective Too many medical beds? One thing is certain about the Audit Commission’s latest report on the health service:...
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