INPATIENT ADMISSION, BED MANAGEMENT AND
PATIENT DISCHARGE IN NHS ACUTE HOSPITALS
IMPROVING PATIENT ADMISSION AND BED MANAGEMENT
5. The National Health Service aims to provide high
standards of care to elective and emergency patients. Since 1992,
specific standards have been set out in the Patient's Charter.
- elective patients can (in 9 out of 10 cases)
expect to be seen for their first outpatient appointment within
13 weeks of written referral by a general practitioner, and all
patients within 26 weeks;
- an operation should not be cancelled on the day
the patient is due to arrive in hospital;
- priority treatment to be within one month if
an operation is cancelled at the last minute;
- emergency patients can expect to be given a bed
within two hours if admitted through an accident and emergency
6. Although some 5.75 million peoplea record
numberwere admitted to hospitals in England as inpatients
in 1998-99, 56,000 patients had their operations cancelled by
their hospitals at the last minute for non-medical reasons. This
was the highest number since the Patient's Charter standard on
cancellations was introduced. Operations are also cancelled before
the planned day of admission and for medical reasons but these
are not always recorded. Around 20 per cent of emergency patients
waited longer than the Patient's Charter maximum of two hours
to be admitted to hospital. And significant numbers of patients
waited for an outpatient consultation in excess of the Patient's
7. We focussed our examination of the scope to improve
patient admission and bed management on:
- the level of cancellations, and ways of reducing
them (paragraphs 8-12);
- reductions in bed numbers and levels of bed occupancy,
and the impact on patient care particularly for elderly patients
- improving admission and bed management systems
- ways of promoting the dissemination and implementation
of good practice, and measuring progress (paragraphs 29-32).
(a) The level of cancellations, and ways of
8. The NHS Executive accepted that no operations
should be cancelled once a patient had been given a date for their
operation, though the reality was otherwise. The NHS was doing
substantially more work to cope with the very significant increases
in emergency admissions and inpatient and day case elective work.
The Executive told us that in the quarter ending December 1999
there had been 11,400 more emergency admissions than in that quarter
in 1998. During that period there had been about 15,000 cancellations1,350
more than in the same period in 1998. There was a direct trade-off
between elective and emergency workloads and people in the health
service had to make difficult choices on a day to day basis. As
well as balancing these workloads and critical care to improve
the management of acute hospital activity, the Executive also
had to balance acute hospital activity with the rest of the system
of primary care, community support and intermediate care options.
9. While hospitals report to the NHS Executive the
numbers of elective operations they have cancelled on or after
the patient's admission, only some hospitals collected information
on cancellations before the day of admission or operations cancelled
on medical grounds.
The Executive told us there was no requirement to record this
data because previous Ministers had taken an explicit decision
in relation to the Patient's Charter to deal with the single issue
of non-medical cancellations on the day. But it was important
for people locally to understand these issues and begin to ask
10. Hospitals need to confirm in advance that patients
are medically fit for their procedure. Early confirmation of a
patient's medical fitness reduces the risk of late cancellation
for medical reasons, and provides the opportunity to invite in
a replacement patient if needed at short notice. The National
Audit Office found that 82 per cent of acute trusts assessed the
medical fitness of some or all of their routine patients in advance
of their planned day of admission. Eighteen per cent of trusts
however assessed this only at the time of admission, thus reducing
the opportunity to invite in a replacement patient if the treatment
could not go ahead as planned. On average 50 per cent of elective
patients were admitted on the same day as their procedure, but
18 per cent of trusts admitted 80 per cent or more of their elective
patients on the same day, thereby helping them to make more efficient
use of their beds.
The Executive told us that cancellations for medical reasons involved
very fine judgements about whether to risk an operation. But with
the right investment in people there was no reason why more trusts
could not develop good practices further over the next few years,
including pre-admission assessments and admission on the day of
11. Patients need to fulfil their responsibility
to inform the hospital if they are unable to attend, so that resources
are not wasted. In 1998-99 around 170,000 patients (five per cent)
failed to turn up for their inpatient or day case treatment.
The NHS Executive said there were often good reasons, for example
elderly patients might not feel well. People did forget about
their appointments and therefore simple improvements could be
made by reminding people in advance, and through explanatory leaflets.
There was a lot of good practice that could be extended into other
parts of the Health Service. The National Patient's Access Team
had been working on this issue and they were seeing improvements.
12. The NHS Executive believed that a more important
way of reducing non-attendance was to improve systems so that
people could book their appointments more at their discretion.
As part of their National Booked Admissions Programme, the NHS
Executive had funded 60 pilot schemes to implement electronic
systems plus the Cancer Services Collaborative, which aims to
extend the benefits to cancer patients. These systems allowed
people to book their outpatient consultation when they were at
their GP, and book their hospital operation when they were in
the outpatient department. The systems also issued reminders two
or three days ahead. These new systems were beginning to show
improvements in the figures for patients not attending. The Minister
of State had announced a third wave of schemes in April 2000,
which requires every acute trust in England to introduce the benefits
of pre-booked hospital appointments and operations in at least
two specialties by March 2002. The Executive were providing financial
support of £40 million for this initiative which included
ongoing support for the 60 pilots.
(b) Reductions in bed numbers and levels of
bed occupancy, and the impact on patient care particularly for
13. The total number of hospital inpatient beds has
been falling for many years. In 1986 there were nearly 200,000
acute and general beds. This had fallen to 147,000 in 1993-94
and then to 138,000 by 1997-98 (Figure 1).
Figure 1 : Changes in the number of hospital
general and acute beds since 1993-94
Note: General beds are mainly used for the care of
older patients. The reduction reflects changes in the care of
Source: C&AG's Report Figure 17
14. Research by the Department of Health showed a
clear relationship between high bed occupancy and the risk of
cancelling elective admissions. The risk became very pronounced
at occupancy levels higher than 83 per cent and this was particularly
true of smaller hospitals with smaller numbers of beds.
15. The average annual occupancy rate for general
and acute beds was 81 per cent in 1997-98. Occupancy levels varied
widely between trusts from around 50 to 99 per cent (Figure 2).
But most trusts reported facing times when the demand for inpatient
beds exceeded availability.
The NHS Executive considered that a sensible level of bed occupancy
for a typical acute hospital was in the range of 80-85 per cent.
There was no one magic number - different hospitals had different
circumstances and demands placed upon them. For example, hospitals
with a high proportion of short-stay, high turnover specialties,
such as Ear Nose and Throat or paediatrics, would not be able
to operate as efficiently at the higher end of the range as those
with more complex cases and a higher average length of stay and
with less turnover.
Figure 2 : Occupancy of general and acute
beds across NHS trusts in England in 1997-98
For each NHS trust, the percentages are measured
by the number of beds occupied by patients at midnight in wards
open overnight, against the number of beds available. These have
been converted to an annual average figure for each NHS trust.
Midnight bed state counts are directly comparable across NHS trusts
and are a consistent method of measuring the number of inpatients
within hospitals. However, they are not able to take account of
variances of shortterm bed availability within each day.
Source: C&AG's Report Figure 18
16. As regards waiting times, it had become clear
during the winter that there were resource problems. The Health
Service needed to staff up to be able to do more work if they
were to give people a more responsive service. The Government
had responded in the Budget by investing more in the Health Service
and the Executive expected that the length of time that people
had to wait would in general reduce.
17. The National Beds Inquiry, published in February
2000, reviewed the assumptions about the growth in demand for
general and acute health services and the implications for the
supply of health services. A key issue for the Inquiry had been
assessing the future need for acute hospital beds by older people
and the scope for alternative models of care, including the development
of community and intermediate care services. Consultation focussed
on how health services and specifically hospital beds should be
developed over the next 10 to 20 years. There had been effective
interaction between the National Audit Office and the Inquiry,
and the Executive were taking account of the additional insights
from the Comptroller and Auditor General's report.
18. The biggest fall had been in general beds - essentially
for older people, but there had been a compensating increase in
the nursing home sector in the period. The reduction in acute
beds had been very small, at just over 2000. Over this period,
a number of factors had led to a reduction in the need for beds.
In the early 1990s there had been a good strategic decision to
invest in day care. A lot of money had been poured into day care
facilities, day theatres, staffing these places differently and
encouraging new ways of working. Now, more than 60 per cent of
all operations were now carried out on a day case basis which
meant that the NHS did not need the same number of beds as it
used to. There had been changes in practice and changes in the
length of time that patients stayed in hospital, for example for
cataract and gall bladder operations, which had allowed the NHS
to reduce beds and deploy resources in different ways.
The growth in admissions since 1980 had been more than offset
by a fall in the average length of stay in hospital.
19. We asked about the impact on the number of beds
of the requirement on the NHS to deliver cost improvements year
on year. The Executive told us that the notion that efficiency
savings could continue to be squeezed out year after year needed
to be challenged. The NHS did not operate to optimum efficiency,
but successive year by year reductions were a blunt instrument
that had had a demoralising effect on people working in the service
and had led to some of the decisions that reduced bed numbers.
Some savings in the number of beds had flowed from changes in
practice, including more day care, and there were fundamental
problems to do with staffing and bed numbers particularly in relation
to services for older people, which the Executive hoped they were
now in a position to resolve. But the NHS was trying to do too
much work given the available resources.
20. We noted that PFI schemes often involved reductions
in beds. The NHS Executive told us that in the first wave of 15
PFI schemes (prioritised in 1997), the business cases developed
for the new facilities, irrespective of whether publicly funded
or by a PFI solution, had reduced the number of beds by an average
of around 11 per cent. Implementation of PFI schemes had actually
resulted in a 10 per cent reduction. For the second wave of six
schemes that had been put out to procurement (prioritised in 1998),
the saving was around 7 per cent in business cases and PFI deals.
However, these figures could not be taken in isolation. They reflected
changes in medical practice, such as day case surgery, separate
provision of extra community beds, and changes in the way services
such as rehabilitation are provided.
21. The Executive told us that the tightness of bed
numbers, the fact that the NHS did not have well-developed services
for older people and that hospitals were working at 85 per cent
plus occupancy meant that there was not enough slack in the system.
People over 65 represented 16 per cent of the population and 36
per cent of hospital admissions, and occupied about two thirds
of beds. The provision and pattern of services for older people
was becoming the key issue. The NHS might need more services particularly
for older people, but they did not have to be based in expensive
acute hospitals. Some other countries had developed a wider range
of community based and home based services. The need to invest
in the concept of a health and social care partnership was now
being looked at in a serious way. The Executive expected to sustain
roughly the existing number of acute beds and an expansion of
intermediate and community based care services for older people.
22. In July 2000 the Government subsequently announced,
as part of the NHS Plan, an increase by 2004 in the number of
beds and places, especially for older people, to help improve
bed availability levels in hospitals. The increase includes 2,100
extra beds in general and acute wards and extra intermediate care
beds and non-residential intermediate care places. They also planned
to issue guidelines on likely future requirements for beds and
types of services which should be available in all areas.
23. In placing patients, hospitals are expected to
deal with a number of factors designed to improve the overall
quality of patient care. These include a national requirement
for single sex adult patient bays; using separate wards for particular
specialties to group patients with similar care needs; and the
need to avoid patients outlying on wards for other specialties.
We asked how often these requirements were breached because of
the pressure on beds. The NHS Executive agreed that this problem
had been widespread, but it was getting better and there were
clear targets for eliminating mixed sex wards. 87 per cent of
trusts surveyed by the National Audit Office reported that they
re-designated beds to match patient categories, including changing
the configuration of single sex bays to match the gender mix of
patients. Hospitals were also physically re-organising their wards
and using information systems to schedule and profile patients
into particular beds. However, almost all trusts placed patients
in wards designated for patients of other specialties if these
were the only beds available, as a way of ensuring that the patient
was placed in hospital.
(c) The scope to improve admission and bed
24. The National Audit Office found that 90 per cent
of acute trusts had designated bed managers whose role was to
ensure that patients were placed promptly in appropriate beds.
This was 19 per cent more than in 1997.
The NHS Executive told us that over the last two or three years
bed management had been given priority and they were now seeing
real and tangible improvements. Good bed managers were knowledgeable
across the whole range of activity and understood the dynamics
of the hospital, and had judgement and engendered trust. For these
reasons bed managers were often senior experienced nurses. They
were now becoming more highly skilled in using information systems
and often had back up staff. It was important that they could
interpret intelligently the information and use it in discussion
with their colleagues.
25. Many bed managers characterised their work as
permanent crisis management, dealing with the immediate problems
of finding a bed for each new patient. Most had to rely on information
systems that were often inadequate. Information on which beds
were occupied and which were available was often inaccurate, out
of date and took time to obtain by physical inspection and telephoning
wards. A small number of trusts had, however, developed more sophisticated
information systems. As an example, the Royal Shrewsbury Hospitals
Trust had developed a system, known as Clinical Applications for
Logistics Management, which had won an NHS Beacon Award. The system
provided real time information on current and projected bed states
as well as bed and theatre resources committed to co-ordinate
elective patient admissions with the resources available.
26. We asked what the NHS Executive were doing to
spread the use of such systems to the rest of the NHS. The Executive
pointed out that they had themselves identified the good practice
at Shrewsbury and that there were other good information systems
around the country, for example in Aintree. They had given Shrewsbury
money to disseminate their practice across the service and a lot
of people had visited the Hospital as a result of the Beacon Award
and the Comptroller and Auditor General's Report. As part of the
NHS Learning Zone there was a database of good practice containing
thousands of entries, which the NHS could tap into electronically.
This included details of all the NHS Beacon Awards, including
the Shrewsbury system. The National Patient's Access Team had
also been advising hospitals on how they could develop such a
system to bring about improvements.
27. The Executive recognised that improving information
systems was a key part of improving bed management. But they did
not think it was possible or desirable to dictate from the centre
how the improvements should be achieved. A key feature of the
success of the system in Shrewsbury was that it operated in a
setting which had other vital ingredients needed for effective
bed management. A successful system depended as much on people,
knowledge, commitment and local circumstances as on particular
technology. They considered it was unlikely that the answer lay
in a single technological solution.
28. The Executive also pointed out that the intellectual
property rights to the system at Shrewsbury were now owned by
a private company, with close links with the SEMA group which
supplied patient administration systems. SEMA were seeking to
upgrade the system and integrate it into their own Patient Administration
System, but did not intend to make it available separately for
integration into other patient administration systems. The possibility
of using the system developed at Shrewsbury had been considered
in Aintree, but rejected because it was not technically possible
without replacing their entire patient administration system.
The NHS Executive had to take a cautious line about actively promoting
a product that benefited one commercial firm, when there were
equally good alternatives on the market.
29. The Executive saw the use of systems like that
at Shrewsbury as a pragmatic, short-term answer. Looking to the
longer term, the Executive wanted networked systems that, as a
by-product of their work on the electronic patient record, provided
real time information on bed utilisation and other data that people
needed to plan well ahead and properly schedule the work. They
told us that their Information Management and Technology Procurement
Review would address how to make best use of the experience and
market position of the NHS and ensure lessons were learned throughout
the service. Inpatient planning and bed management systems would
be part of that process and specifications would be informed by
the Shrewsbury project and other similar projects, but it would
be up to suppliers to demonstrate value for money and tailored
(d) Ways of promoting the dissemination and
implementation of good practice, and measuring progress
30. The NHS Executive have established a range of
initiatives to encourage the development and spread of good practice
in access to patient treatment across the National Health Service
Figure 3: The NHS Executive's initiatives to encourage
|Emergency Services Action Team
||Identify and spread good practice, and advise on handling of winter emergency pressures.
|Waiting List Action Team
||Achieve the sustained reduction in patient waiting lists; and secure effective implementation of national policies that improve services for elective patients.
|National Patients' Access Team
||Extending use of best practice and working locally to solve bottlenecks that slow patient care; develop new and innovative approaches to patient care.
|NHS Beacon Awards||Awarded for innovative or best practice. Experience is shared with the NHS through a range of practical learning activities.
Source: C&AG's Report paragraph 10 and Figure
31. The NHS Executive gave us examples of the use
of special targeted funding to get new initiatives off the ground.
These included the £365 million to encourage schemes across
the health and social care boundaries, and £115 million allocated
to fund a programme of modernising Accident and Emergency Departments,
including the way they work and function.
They acknowledged some frustration at the speed that initiatives
were rolled out, but as the Comptroller and Auditor General's
report showed, between 1997 and 1999 there had been tangible progress.
They hoped that with more resources and more commitment to drive
good practice forward they would be able to do even better.
32. As part of this, they were discussing with Ministers
how they could use recently announced additional NHS funding to
encourage best practice. They were looking at the way the system,
money and non-financial factors, incentivised people to adopt
good practice and to avoid perverse incentives. Unless people
had time to assimilate new ideas and work them through on their
own terms, and were supported by sufficient administrative and
information technology resources, change would not happen.
33. The Executive told us that NHS was highly productive
when set against European comparisons, but this masked all sorts
of difficulties and was not a descriptor of the quality of care
or of the pressures and difficulties faced by staff.
It was important to get a more rounded picture of performance.
They had been working with the Treasury on a new performance assessment
framework which took account of health outcomes and the patient's
experience, as well as harder edged measures of efficiency. They
had set up ways of measuring the qualitative aspects of healthcare
through the Commission for Health Improvement and the Audit Commission,
and had launched for the first time patient reaction and user
They would continue to measure take up of good practice against
the parameters set out in the Comptroller and Auditor General's
report, which gave them a good template. With the qualitative
information and the results of their patient surveys they would
know if they were making progress in the round.
34. NHS trusts record the number of operations that
are cancelled on the day of admission and the numbers of patients
that do not turn up for their appointments. But most trusts do
not know the extent of other cancellations that occur either before
the day of admission or because the patient's medical condition
does not allow the operation to go ahead. NHS trusts should improve
their recording and understanding of cancellations to help them
improve their working practices.
35. Hospitals could make better use of their resources,
including beds, by reducing unnecessary cancellations for medical
reasons or because patients do not turn up. Good practice, such
as the use of pre-admission assessments, admitting patients on
the day of their treatment, and improved booking systems need
to be implemented more widely. The National Booked Admission Programme
provides a good way of helping to drive through change.
36. The total number of hospital inpatient beds has
been falling for many years. In 1986 there were nearly 200,000
acute and general beds. This had fallen to 147,000 in 1993-94
and then to 138,000 by 1997-98. There is a clear relationship
between high bed occupancy and the risk of cancelling elective
admissions. This risk becomes very pronounced at occupancy levels
above 83 per cent. Bed occupancy rates in hospitals ranged from
around 50 per cent to 99 per cent in 1997-98. The average across
all hospitals was 81 per cent.
37. Changes in clinical practice over the years have
enabled hospitals to treat more patients with fewer beds. But
we are concerned that some hospitals are now operating at very
high levels of bed occupancy of up to 99 per cent. The combined
effects of year on year efficiency gains may have restricted hospitals'
ability to cope with the increasing demand. We note that additional
funding is now being made available to help provide a more responsive
38. The biggest fall has been in general beds - essentially
for older people, though there has been a compensating increase
in the nursing home sector in the period. While people over 65
represent 16 per cent of the population and 36 per cent of hospital
admissions, they occupy about two thirds of beds. The provision
and pattern of services for older people is the key issue. Additional
funding and facilities have been announced in the Budget and in
the NHS Plan of July 2000.We look forward to the introduction
of more detailed guidelines for assessing future bed requirements
and the balance to be achieved between different types of services
at local level.
39. Good information systems that provide real time
information on current and planned use of key resources are essential
in helping bed managers and other hospital staff to plan patient
admissions effectively. Some trusts have succeeded in developing
good systems, for example at Shrewsbury. However, in many trusts
systems are inadequate and adapting existing systems can be complex.
The NHS Executive plan to incorporate inpatient planning and bed
management within their wider strategy for developing network
systems and the electronic patient record. Our concern is that
until these systems are available, many trusts will continue to
operate for the foreseeable future without the information they
40. We are therefore disappointed that the NHS Executive
have not done more to build on the success of the system developed
in Shrewsbury. The NHS has a record of slow and patchy progress
in implementing IT projects, as we have seen in our previous hearings
most recently on the Hospital Information Support Systems Initiative
(HC 97 of Session 1996-97) and the 1992 Information Management
and Technology Strategy (HC 406 of Session 1999-2000). When successful
systems are developed, with real demonstrable benefits to patients,
the Executive need to invest in implementing them more widely,
rather than leaving NHS Trusts to re-invent the wheel. In taking
forward the new NHS IT Strategy, the NHS Executive therefore need
to work with NHS trusts to ensure they have a clear understanding
of the likely timing and impact of the new systems, and of the
costs and benefits of implementing interim solutions in the short
41. The Comptroller and Auditor General's report
demonstrates clearly the scope for more NHS trusts to introduce
and build on the range of good practice in bed management and
managing patient admissions. The NHS Executive have a key role
to play in disseminating and encouraging good practice, and they
have launched a number of initiatives. They are also looking at
how additional funding can best be directed to support and incentivise
the wider application of good practices. The success of these
new arrangements will depend on getting the right balance of guidance,
instruction and incentives to ensure that hospitals and other
agencies introduce the changes needed. The NHS Executive need
to track progress closely, evaluate the impact of these measures
and take remedial action where progress is slow.
3 C&AG's Report (HC 254, Session 1999-2000), paras
5, 1.13 and Figure 2 Back
ibid, paras 6, 1.11-1.13 and Evidence, Appendix 3, p25 Back
Evidence, Qs 3-5, 87 Back
Report (HC 254, Session 1999-2000), paras 1.10-1.14 Back
Qs 91-92 Back
Report (HC 254, Session 1999-2000), paras 1.29-1.32 Back
Report (HC 254, Session 1999-2000), para 1.26 Back
Qs 20-21, 78-80 Back
Qs 21, 45-48 and Evidence, Appendix 1, pp 22-23 Back
Report (HC 254, Session 1999-2000), para 2.5 and Figure 17 Back
Q148 and Evidence, Appendix 1 pp 22-23 Back
Report (HC 254, Session 1999-2000), para 2.9 and Figure 18 Back
Qs 5, 67 and Evidence, Appendix 1, pp 22-24 Back
Qs 4-5 Back
Report (HC 254, Session 1999-2000), paras 2.7-2.8 and Evidence,
Qs 14, 50-51, 140 Back
Report (HC 254, Session 1999-2000), para 2.8 Back
Qs 5, 50-52, 69-70, 138 Back
Qs 53 and Evidence, Appendix 1, pp 22-24 Back
Qs 6, 14-16, 56 Back
NHS Plan, Cmnd 4818-I, July 2000 Back
Report (HC 254, Session 1999-2000), Figure 15 Back
para 2.35 and Evidence, Q81 Back
para 2.22 Back
Qs 22, 122-126 Back
Report (HC 254, Session 1999-2000), paras 1.23, 2.24-2.29 Back
Qs 7, 33, 39 Back
Qs 37, 41, 47 Back
Qs 35-48 and Evidence, Appendices 1-2, pp 22-25 Back
Q7 and Evidence, Appendix 1, p22 Back
Report (HC 254, Session 1999-2000), para 10 Back
Qs 9, 19 Back
Qs 89-90 Back
Qs 11, 139 Back