Shroud-waving, round 1

A Hill-Rom hospital bed

How many of these do we really need?

Before we all jump off cliffs over apparent bed shortages in hospitals in the UK, we need to keep in mind at least two points.

1. According to the OECD in 2009 (a reliable source of comparative data), the UK has 4.1 beds per 1000 people, higher than the US at 3.6, Canada at 3.9, about the same as Spain but certainly less than say France at 8.4 or Germany at 9.2. Countries with higher bed numbers also use hospitals a lot more for things can be treated in primary care, a preference shared by many patients. Using less beds does not equate to a shortage of beds.

2. Beds themselves are not what there is a shortage of, but the ways they are used. The UK is broadly quite efficient in bed use (which is code for how long a patient is in a hospital, and how quickly a bed can be turned around between patients, but which is frequently determined by what time of day they are discharged. Patients can be kept in hospital over a weekend for example, instead of going home at lunch on a Friday simply because the hospital lab may not be able to turn around tests to confirm the patient is well-enough to go home. So for what might be a few extra hours of lab time, a patient and a hospital can incur three extra hospital nights: Friday, Saturday and Sunday.  Moving to fuller use of weekend working, plus at least 18 hour/day labs and imaging reduces these delays. As well, greater use of day-case procedures keeps patients out of an overnight stay; a good day case unit should run three day case shifts over the course of the day. This increases throughput and uses the infrastructure more intensively. Which does not reduce the high touch side of care, you just don’t need to be in hospoital for as long.

It is in the interests of healthcare vested interest groups to fixate on bed numbers as this is a simple measure, easy to cite, there is a finite number of them and fewer appears worse than more, so that presumably having more would be better and without more, dire things will happen to patients.

Such shroud-waving ignores that fundamentally more complex processes underpin poor use of beds, and hence treatment of patients. Improved pain management for example can chop a whole day of how long a patient needs to stay in hospital. Improving how efficient the operating theatre is can reduce how long a patient is under an aesthetic and so shorten the hospital stay — you don’t want to look at how poorly run operating theatres are, in terms of time management or surgical performance.  As a simple example, using a robot arm to hold the endoscopic camera rather than employing someone to do this reduces surgical time dramatically but how many of these are in regular daily use — how widely adopted is this technology, which is made in the UK?

Given that the UK’s four health systems have to look hard at spending, we should avoid a fascination with bed numbers, and indeed whether local authorities/municipalities can and can’t afford to do things. There is nothing stopping a well-run NHS Trust from investing in an effective free-standing step-down unit to handle the shift of patients into the community or contracting with the surplus capacity of nursing homes to provide skilled nursing care.

Yes, this doesn’t solve the whole problem, but it solves parts. Health systems are complex, and chipping away is often a rational strategy to avoid centrally planned chaos. The whole point of shifting the system toward more local decision-making is to enable creative solutions.

There is always room for improvement in healthcare, but having more beds does not always equal patients being treated particularly well or effectively or indeed being treated at all.  It is important that we keep this difference clear.

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