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

Lack of social care is piling pressure on surgeries and A&Es

20th March 2017

Almost 9 out of 10 GPs (89%) think reductions in social care are leading to extra pressures in their surgeries. Even more (93%) think that the lack of social care is leading to extra pressure on A&Es and contributing to increased delayed discharges from hospital.

Ahead of next week’s budget, the poll of over 1000 GPs reveals an overwhelming 92% of GPs think social care services are failing to give patients sufficient care. Currently at least 1.2 million older people and disabled people (1) do not receive the care they need, a 48% increase since 2010. When people don’t get the basic care they need, they are more likely to fall into crisis and need more expensive medical attention.care servicesKey findings include:

  • 9 out 10 GPs (92%) are not confident that social care services currently provide a sufficient level of care for patients.
  • Almost 9 out 10 of GPs (89%) think reductions in social care have contributed to pressures in their surgeries and (93%) think this has led to increased pressures in A&E and contributed to an increase in delayed discharges from hospital.
  • GPs also think that things are going to get worse, with 8 out of 10 GPs (81%) thinking care services would worsen over the next two to three years.
  • Almost 9 out 10 GPs (88%) think that due to cuts to social care there is less care than just two years ago
  • Nearly 1 in 3 (31%) GPs thought that 1 – 5% of appointments could have been avoided if better social care was in place, another 30% thought 5 – 10%, and more than 1 in 10 (12%) thought as many as 21 – 30%.

Vicky McDermott, Chair of the Care and Support Alliance, said:

“Our social care system is letting people and their families down by denying them basic care such as help getting out of bed, getting out of the house or even having a fresh meal. More than a million people with difficult conditions are being denied the chance to live as well as they deserve.

“GPs are on the front line, a witness to what happens when you take basic care away from people – it damages their health and means they need more expensive care from the NHS.

“Philip Hammond needs to use the budget to invest in social care. The Government needs to address the crisis in social care, which is resulting in the NHS picking up the tab and people not getting the care they need.”

The poll was commissioned by the Care and Support Alliance (CSA) – a coalition of more than 90 of the country’s leading charities – who are calling for a properly funded care system.

The coalition has warned that the Government’s attempts to increase funding into social care have been being inadequate and “a drop in the ocean” compared to what is needed. Social care funding has fallen by £4.6 billion, a third, over the last 5 years (2).

Hospitals are experiencing record delayed discharge, with delays because of a lack of home care increasing by 230 per cent from August 2010 to Dec 2016. Last year the NHS lost 650,000 bed days (3), costing the NHS up to £300 million (4). NHS Chief Simon Stevens last year highlighted: “The most immediate need is social care. If home care disappears and care homes close, A&Es are quickly overwhelmed. We need creative solutions.”

One in eight over 65s has some level of unmet need (5). In the UK, around one in three people rely on, or have a close family member that relies on, the care system (6). Currently carers provide care worth £132bn, the equivalent to the UK’s total health care annual spend (7) and over 2 million people have already given up work to care.

Social care user Rachel Looby, 34, from Harrogate, needed medical help after her hours were cut. She said:

“When my hours were cut it was a stressful time for me. I took the wrong medication and ended up in hospital, and this made me feel like my health had not been considered at all. Being in hospital left me feeling anxious and upset and I worried if something else might happen once I got home.”

Dr Jon Orrell, a practising GP from Dorset, added:

“As a GP for 30 years I have never before seen patients being let down by social care services as they are now. I see patients who are unable to feed themselves or cook being bounced back to the NHS to get food supplement cartons to drink alone, instead of real meals.

“Recently I had a case of a son who had been caring for his mother and despite being granted respite breaks he never received it because funding was cut. Eventually,he became exhausted and his mum had to go to hospital. I regularly see the false economy of cutting social care, people only end up needing more help because basic care wasn’t there in the first place.”

Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, said: “Colleagues right across health and social care are currently struggling to meet growing patient demand, with scarce financial and workforce resources – and it is our patients who are suffering the consequences.

“When social care is not properly resourced, it undoubtedly has a knock-on effect on GPs and our teams, as well as our colleagues working in hospitals. We must start seeing good healthcare as a tripod, with robust general practice, hospital and social care services as three linked elements; all must be appropriately resourced, and all working together in harmony, for us to provide care that is in the best interests of patients.

“We hope these figures encourage the Government to review funding for the whole of health and social care – and to implement the pledges made in NHS England’s GP Forward View, including £2.4bn extra a year for general practice and 5,000 more full time equivalent GPs by 2020 – so that we can all deliver the care our patients need and deserve.”

Personal story of how social care cuts led to need for NHS care:

Rachel’s Story 

Rachel, 34, from Harrogate is visually impaired, has dyspraxia and autism.

For a long time Rachel received 17 hours support a week. This involved help with basic tasks such, as cleaning and cooking, as well as help with managing her money, medication and personal care.

However her support was reduced to just five hours per week. This meant she only had help with basic tasks. With no one to help her manage her medication Rachel missed doses and had a seizure. To make things worse, while recovering Rachel mistook her dog’s flea medication for her own and became very ill for which she had to be hospitalised.

These two incidents, understandably, knocked her confidence, and she became demotivated and stopped taking her anti-depressant medication. This led to her becoming depressed and socially isolated.

For more information or interviews please contact either

Mel Merritt – Care and Support Alliance 

020 7923 5770 /mel.merritt@csa.org.uk

Warren Kirwan – Scope 

020 7619 7702/  warren.kirwan@scope.org.uk

The polling

Medeconnect polled 1006 regionally representative GPs between 14th and 23rd February 2017. 

Notes to Editors