The most important point in the bed narrative is that beds need staff
For many hospitals, winter is, in an operational sense, almost upon us, so a King’s Fund review of the historical, current, and likely profile of “beds” in the acute sector of our health economy is a timely one. Perhaps the most striking feature of their paper is the sense in which “beds” have become the currency of choice by which we measure the viability, sustainability, and strategic legitimacy of our healthcare system.
The pressures on bed stock in England are undoubtedly unprecedented; the fact that most, if not all, of the operational hospital meetings that occur scores of times across the land each day are termed “bed meetings” exemplifies the forensic scrutiny with which we manage this most basic yet most evocative item of furniture. But in reality, of course, for “beds” we mean “patients”; for “patients” we mean “people”; and for “people” we mean vulnerable, sick, injured, and distressed people looking for help and support at their time of greatest physical and psychological need. Imagine for a moment if we re-named our meetings “patient meetings” not “bed meetings.”
The review highlights some important points for reflection. Although it is true that there has been a 33% rise in people aged 65 and older between 1987 and 2016, it does not follow that all these people need a bed in a hospital just by virtue of age; people are living longer but they are living healthier, too; the correlations are not straightforward. Age doesn’t equate to frailty; many older people are healthy and many younger people are frail. Likewise, although we talk often of “step down” facilities—intermediate care—our health economy has a brisk and ruthlessly efficient “step up” facility in the shape of an emergency ambulance. We can, as a healthcare system, re-contextualise someone from being in their sitting room of a nursing home to being part of a hospital four-hour target challenge within about 10 minutes via a blue-light ambulance; the process of getting them back to the home might then take 10 hours or 10 days. We need to do much more to ensure we provide clear, consistent care models into place that see us have fit-for-purpose community response processes in place for our most vulnerable patients 24 hours a day, seven days a week: response processes that don’t end at 6pm, or that are absent at a weekend, or if someone calls in sick. Therein lies our problem in how we conceptualise “demand”, because as we speak we are creating “demand” by virtue of not properly addressing the true nature of effective “supply.” The “demand” on our healthcare system is in reality a self-created one and we are now scrabbling, within the acute sector, to muster what “supply” we can for a “demand” that asks quite different things of all of us. As before, for “demand” read “patients”, and for “patients” read “people.”
Perhaps the most important point in the bed narrative is that beds need staff; moreover they need many staff, with a range of complementary skills, working in concert within a well-rehearsed and consistent model of rostering. We are struggling within the acute sector to provide these staff because they are not procured like beds but are nurtured, supported, trained, and encouraged to progress over many years. “Taking beds out of the system” is, for an acute provider, shortcut for “wholesale reconfiguration of workforce planning” and for that we need time, space, and money. One cannot drive the other; they are necessary but quite different elements of the same thing—effective strategic planning with a commitment to stick at it through good times and bad over a minimum 10-year cycle. We have some way to go.
Meanwhile, there are things we can control but in themselves need almost similar levels of support, time and tenacity. We do need to tackle unwarranted variation, but we need to recognise that there are ceilings of productivity within any given area of practice. We are arguably at those ceilings now in many areas; where we are not, we need to be much more open to support of our neighbours and colleagues and work more operationally in supporting one another. This isn’t “best practice,” this is “better practice” and there is a difference in ethos between those phrases. We need to fully understand where our existing workforce is through the day, better enable them to use their skills and time effectively through consistently-led electronic rostering and activity management, and to ensure that staff have access to good educational support. We need to role model well. We need to look after each other.
Perhaps the most powerful message within this review is that “beds” as a currency of healthcare may have reached their pre-decimal point of expiry. Perhaps, instead, we need to think more about what our measures of system health are through acuity, timeliness, staff-to-patient ratios based on consistently-applied physiological scoring. Meanwhile we need sufficient resources to give us headroom in supporting those changes across the piece. Beds are cheap—the expense comes from the staff and infrastructure needed to turn them from items of furniture into microcosms of high-quality and compassionate care around the clock. More “beds” does not, then, mean more “care”. Let’s measure, describe, and implement the care—and only then decide if beds are the thing we need to enact it, because “beds” and “demand” are “patients”—and “people.”
Darren A Kilroy is the Deputy Medical Director at East Cheshire NHS Trust with portfolio responsibility for medical workforce and Divisional Medical Director at Countess of Chester NHS Foundation Trust with portfolio responsibility for Planned Care. He is an advisor to NHS Improvement in relation to medical workforce.
Competing interests: None declared.