Hospital Beds

When the coronavirus pandemic is over, one of the things which I hope we can learn something from is to get a more balanced policy on hospital beds.

Over more than forty years, starting as a teenage volunteer, during which I have been involved in the NHS - as volunteer, campaigner, health authority member, hospital manager (unpaid, holding this legal status for the purpose of Section Two appeals) and health scrutiny member, the thread which has most consistently run through my experience as I have heard members of the community debate with those who run the NHS has been the prayer,

"If only each side would listen to the other more and recognise that there are things about which the other side is right.

One of the most positive developments in the last few years in North Cumbria has been that under what is called "Co-Production" or "Working together" some of the barriers have come down and the community and NHS leaders have listened to each other more in both directions. We need to do much more of this and I hope it is not a casualty of the pandemic.

I've thought that community, staff and NHS leaders need to listen to each other more about maternity, accident and emergency services, stroke services, medical records, mental heath provision, vascular services and paediatric care, but the classic example has been hospital beds.

For decades under governments of every party, in every in of financial position from boom to bust and from rapidly increasing spending to times of austerity, the number of NHS beds has been trending down.

Whatever your politics are, right, left or centre, if you think this is all down to people who have different political views from yours or of spending policies you don't like, you are wrong. Because people of every political colour from UKIP to the Labour left and of no party politics at all have been involved and have been at the heart of such policies, and both shortage of money or extra investment equally seem to drive the process faster.

For as long as I have been in a position to have a view about what was going on in the NHS, successive generations of NHS leaders - and I don't just mean the administrative management, this has been coming from doctors and other clinicians and professionals as well - have been seeking to find more efficient ways of care by treating people "closer to home," which includes reducing the length of stays in hospital and redirecting care into the community (a phrase which originated with mental health but is often used for other forms of care.)

This is rarely about saving money because the new policies are usually more expensive. It's about reducing the damage to people's health which long stays in hospital can cause, from bed-sores to hospital-acquired infections. 

Often the broad thrust is right. Sometimes it is absolutely wrong, as when  my wife scathingly and rightly in my opinion, suggested that a North Cumbria health strategy called "Closer to Home" should be called "Further away from home" because the consequences would include moving services from West Cumbria to Carlisle, Hexham or even Newcastle.

But the one thing which seems to go wrong every time, even when I think the overall policy is right, and has been an issue in each of the four decades I have been involved in the NHS is that whoever is running the service, when they reconfigure the service, they always take too many beds out.

I had this discussion thirty years ago with Roger Stokoe, later president of the Institute of Health Management and a man for whom I had a great deal of time, when he was general manager of North West Herts Health Authority and I became a member of the authority in my twenties.

I had the same discussion as a member of the public and campaigner with his and my successors as managers and members of the trusts which provided NHS healthcare in Hertfordshire over the ensuing decade.

In the first decade of this century I had a similar conversation in Cumbria with Professor John Ashton when he was Director of Public Health and an employee rather than a critic of the then government (although to be fair he was often nearly as rude about the health policy of his own party as he has subsequently been about Conservative policy!) From the second decade of the century and into the twenties I have put the same points to Steven Eames when he was running the "success regime" consultation and to both him and other leaders of the NHS in North and South Cumbria much more recently as a health scrutiny councillor.

Each successive plan, however well intentioned, however often most of the principles are right, invariably seems to make assumptions about demand for beds, about how successfully some beds can be "ring-fenced" for operations, and hence about bed utilisation which turn out to be too optimistic. And we always end up running too close to the line, and with bed numbers which are not high enough to be sustainable for the pattern of service.

I said earlier this year at what may turn out to have been the last Health Scrutiny meeting for some time that next time we come up with a reconfiguration - and hopefully improvement - in the service which reduces the needs for beds, instead of taking all the beds theoretically saved out, we should take the opportunity to plan for a lower utilisation rate. 

If we did that, fitting all the patients into the beds available might be less like one of those puzzle games where you have to slide tiles with the pieces of a picture around until you can assemble it into the right shape. It might mean there was more time to clean the beds between patients and a lower rate of hospital-acquired infections.  

The whole world is in the process of learning the hard way how much you can sometimes need to expand health service capacity.

The deal which has been struck in the UK with the private sector, providing 8,000 more beds and 20,000 more medical staff will undoubtedly help - but the pressure on NHS resources and staff is, and will remain for weeks, enormous.

This probably won't be the last pandemic. The next new bug may be more lethal than COVID-19; at least this one hardly ever kills children or people with their whole lives before them. I hope we are all ready to recast our views on what it means to be prepared.

Everyone involved in planning for health care - clinicians, administrators and politicians alike - is going to have to learn lessons from this, both in terms of planning for future unexpected shocks to our health service and in terms of what it tells us about how things run on a normal basis.

It's too early to predict what many of those lessons are going to be. But it is probably not too early to suggest that we need to have a good hard think about how we use hospital beds and how many of them we need to have available.