Hospital bed numbers – can the downward trend continue?

Since sustainability and transformation partnerships (STPs) published their plans late last year, the issue of the number of NHS hospital beds has been rising up the health care agenda. Alongside integrating health and social care and boosting primary and community services, some STPs – for example Dorset, Derbyshire and some STPs in London – have included proposals to reduce the number of hospital beds in their plans.

Subsequently, some stakeholder groups have voiced concern: for example, the Royal College of Emergency Medicine thinks that the NHS needs more beds, not fewer, if it is to meet performance targets. So we decided to look into the number of hospital beds, explore trends and ask if it’s realistic to reduce numbers further in the coming years.

Hospital Beds

The NHS has been reducing the number of beds for decades: since 1987/8, the total number has more than halved from around 299,000 to 142,000. Within that, the numbers of beds for people with learning disabilities and mental health problems have fallen more substantially – by 96 and 72 per cent respectively. Several changes in the way that care is provided have made these reductions possible. For example, care for people with mental health problems and learning disabilities has gradually shifted from institutional settings into the community; technical improvements in surgery have meant more patients undergo day surgery – in cataract surgery almost all operations are now day cases; and average length of stay for hospital patients has fallen from eight to five days over the past 15 years thanks to developments in clinical practice and how patients are managed.

But can this downward trend in number of beds continue?

On the one hand, there are clearly opportunities to use hospital beds more productively. As the Getting It Right First Time initiative has highlighted, there are substantial variations in average length of stay for some procedures across different hospitals. Variations in how complex older patients are managed means these patients spend more days in hospital in some areas of the country than in others. And many patients experience delays in the discharge process meaning they spend time in hospital when they are no longer benefiting from being there. In July this year, more than 5,860 beds were occupied by patients whose discharge was delayed. Progress in these areas would help to make more productive use of existing hospital beds. While national NHS leaders are keen to make such progress, it is unlikely to be straightforward, as recent tensions between NHS England and local government over efforts to cut delayed transfers of care exemplify.

On the other hand, however, today there are a number of factors that make the wisdom of reducing the number of hospital beds far more uncertain than it may have been in the past. England’s population is growing and ageing: by 2030 one in five people in England will be aged over 65, and therefore more likely to need health care. Demand for hospital care is rising with increases in A&E attendances, emergency admissions, and elective admissions. In turn, bed-occupancy levels in hospitals have risen to new highs in the past few years; in 2016/17 overnight general and acute bed occupancy averaged 90.3 per cent. Reductions in average length of stay have slowed in recent years, and may well slow further in the years ahead. Out-of-hospital services – particularly intermediate care and social care – which play a key role in supporting people as they leave hospital are under real strain with access to publicly funded social care becoming more difficult. Finally, the simple fact that the vast majority of beds for those with mental health problems or learning disabilities and beds for the long-term care of older people have already been closed means there is very little scope to reduce numbers further. Instead, future reductions in the number of hospital beds would mean reducing the number of acute beds, which historically has been more difficult. These factors help to explain why the pace of reduction in the total number of hospital beds has slowed in recent years – falling only around 4 per cent between 2012/13 and 2016/17 – and why bed-occupancy levels have risen.

The NHS’s record over the past 30 years is one of success. Adopting new ways of providing care has allowed the service to provide higher-quality care to increasing numbers of patients while reducing the number of hospital beds. But it doesn’t follow that the number of beds can be reduced indefinitely. Today circumstances make it less clear how patient needs are going to be met effectively if more beds are closed – particularly in light of the lack of money to develop alternative out-of-hospital services. So, while some areas may be able to safely reduce the number of beds, substantial reductions in the total number of NHS hospital beds in the next few years seem neither achievable or desirable.

Source: Leo-Ewbank at the King’s Fund

Is investment in GP services increasing?

Beccy Baird writing at the Kings Fund: Last year we published a report highlighting the crisis in general practice. There are strong signs that general practice continues to be under increasing strain, including a rise in complaints about GPs, surveys showing patient satisfaction – particularly with access – is declining, and reports of all GPs in an area closing their registered lists as they feel unable to take on more patients.

The government and the national NHS bodies have made attempts to recognise and address the issues facing general practice. In April 2016, NHS England published the General practice forward view, which outlined a range of initiatives and investment for general practice. Among the measures it introduced were a programme to address some of the administrative burdens placed on GPs, initiatives to improve mental health support for GPs and support to deal with rising indemnity costs. Many of the measures focused on recruitment, both through training more GPs and by recruiting from abroad, although figures so far suggest that the government’s target of 5,000 more GPs by 2021 will not be met.

Financial investment in general practice is mind-bogglingly hard to track, and there isn’t any published data that fully profiles promised investments over the period covered by the General practice forward viewNew figures from NHS Digital show that spending in general practice increased in real terms in 2016/17 compared to 2015/16 (though by less than the increase between 2014/15 and 2015/16), but it is still unclear how much of this increased investment is actually reaching frontline services. This is particularly true for the money GPs receive outside their core contract. For example, the overall increase shown in NHS Digital’s figures includes financial flows which don’t reach GP practices directly, particularly payments for information management and technology, which accounted for about 29 per cent of the overall growth in investment.

King's Fund

NHS England has indicated that in future significant additional funds for general practice will have to come from local commissioners, particularly the Sustainability and Transformation Fund. However, it’s highly unlikely that much, if any, of this spend will materialise in the near future as the Sustainability and Transformation Fund is used to offset deficits in other parts of the system, especially acute hospitals. In the past, NHS England has also suggested that as clinical commissioning groups build new care models in line with the NHS five year forward view that investment in general practice would grow even further. However, NHS England’s latest annual accounts show commissioners underspent the budget for primary care and secondary dental care by about 2.3 per cent in 2016/17, suggesting that this increased flow of money to general practice is not happening.

Overall the money does seem to be going up, but by exactly how much and whether it’s in line with the promises made in the General practice forward view (namely to increase spend by 14 per cent in real terms between 2015/16 and 2020/21) is unclear. There’s also no way of knowing whether this money is enough to meet the rising demands placed on GPs. We’ve talked endlessly about the lack of good-quality national data which means it’s hard to know how much extra investment is needed. NHS England is working hard to address this, but it will be a long and complex process to address the lack of national data.

But there is good news. Last week the Care Quality Commission published its first report on the state of general practice. There was much to celebrate in the report, with the majority of general practices found to be providing safe and high-quality care despite the ongoing challenges of rising demand. What particularly struck me was how strongly correlated communication and relationships were with good-quality care. Practices where clinicians were connected to others, within the practice, in their community and in wider professional networks performed better than those that were insular and inward looking. These better practices have been developing innovative ways to deliver care and there are many examples of creative thinking, including the primary care home models, community-based models and new ways of reaching specific population groups. This needs to be the way forward. There could be a focus solely on delivering more of the current model, faster, by finding more GPs, adopting new technologies and improving the understanding and management of patient flow. But the realities of recruitment and retention challenges mean significantly greater numbers of GPs are unlikely and the changing health needs of the population, with growing numbers of people with complex long-term conditions, mean these approaches alone are unlikely to meet patient needs.

The Fund is launching a new project to look at innovative delivery models in general practice from the UK and internationally, seeing if we can distil from these a set of design principles that might guide practices developing new ways of working. We’d love to hear from GPs who are innovating in this way – please get in touch.

Source: The Kings Fund