House of Commons - Public Accounts

Select Committee on Public Accounts First Report

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. These include:

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 department.[3]

6. Although some 5.75 million people—a record number—were 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 Charter standard.[4]

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 (paragraphs 13-22);

improving admission and bed management systems (paragraphs 23-28);

ways of promoting the dissemination and implementation of good practice, and measuring progress (paragraphs 29-32).

(a) The level of cancellations, and ways of reducing them

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 cancellations—1,350 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.[5]

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.[6] 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 questions.[7]

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.[8] 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 treatment.[9]

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.[10] 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.[11]

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.[12]

(b) Reductions in bed numbers and levels of bed occupancy, and the impact on patient care particularly for elderly patients

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).[13]

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 older patients.

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.[14]

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.[15] 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.[16]

Figure 2 : Occupancy of general and acute beds across NHS trusts in England in 1997-98

Note

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 short—term 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]

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]

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.[19] The growth in admissions since 1980 had been more than offset by a fall in the average length of stay in hospital.[20]

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.[21]

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.[22]

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.[23]

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.[24]

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.[25] 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.[26]

(c) The scope to improve admission and bed management systems

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.[27] 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.[28]

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.[29]

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.[30]

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.[31]

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.[32]

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 solutions.[33]

(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).[34]

Figure 3: The NHS Executive's initiatives to encourage good practice

Initiative	Role
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 11

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.[35] 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.[36]

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.[37]

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.[38] 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 surveys.[39] 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.[40]

Conclusions

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 service.

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 need.

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 term.

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

4 ibid, paras 6, 1.11-1.13 and Evidence, Appendix 3, p25 Back

5 Evidence, Qs 3-5, 87 Back

6 C&AG's Report (HC 254, Session 1999-2000), paras 1.10-1.14 Back

7 Evidence, Qs 91-92 Back

8 C&AG's Report (HC 254, Session 1999-2000), paras 1.29-1.32 Back

9 Evidence, Q22 Back

10 C&AG's Report (HC 254, Session 1999-2000), para 1.26 Back

11 Evidence, Qs 20-21, 78-80 Back

12 Evidence, Qs 21, 45-48 and Evidence, Appendix 1, pp 22-23 Back

13 C&AG's Report (HC 254, Session 1999-2000), para 2.5 and Figure 17 Back

14 Evidence Q148 and Evidence, Appendix 1 pp 22-23 Back