You’ll have seen endless reports of long waits in overcrowded Accident and Emergency departments, ambulances queuing outside and distressed patients in corridors waiting for beds. How have we come to this in a wealthy first world nation?
The reports are no exaggeration. The statistics don’t lie. Those numbers are people; sick patients and scared relatives, with harrowing human accounts. Caring professional staff are doing their best in a pressurised, morale-sapping, high-stakes environment.
Our beds are over 90 per cent full year round. Hospitals start each day short of beds and scrambling to empty some to make room for the next wave. Rammed beds mean no flexibility for even a small surge in local demand, for instance from infection outbreaks, which in turn spread on over-packed wards.
The key four-hour A&E waiting time targets for NHS hospitals have been missed for several years. More patients than ever wait for over 12 hours. Performance is the worst since we started measuring against them. Waiting times for planned operations are also hit when emergency patients are admitted to those beds.
The number of patients attending major A&E departments in general hospitals has near doubled in the past 20 years. Although some brand new departments have been built and others extended, they are rarely designed or staffed for the numbers of patients now using them.
Campaigns and political commentators repeatedly highlight use of A&E or ambulances by people who don’t count as accidents or emergencies and might have used a walk-in urgent care unit or gone to a GP if only they could get an appointment. We are urged to see a pharmacist, use advice lines or websites, manage our own conditions and stay away.
An estimated 15 to 20 per cent of attendees are people with problems that don’t technically need A&E. But those patients are generally assessed in chairs and go home. GP workload and attendance at walk-in units have risen as fast as A&E attendance in any case. These patients are not the cause of the problem. Keeping more of them away won’t solve it.
The main cause of the overcrowding and long waits is patients who need onward admission from A&E to beds which are occupied and unavailable. The older, frailer and sicker you are, the more existing long-term medical conditions you already have, the more likely you are to need admission. These patients are especially at risk of harm or distress from long trolley waits in corridors.
But why so few beds? First, even as demand has risen, the population grown and aged, we have lost around a quarter of our hospital beds over the past 30 years as part of deliberate policy direction and poor planning based on poor modelling assumptions. New-build hospitals have often had fewer beds than ones they replaced. The UK is at the bottom of the OECD league of bed numbers per 1,000 people with less than half what the Netherlands, Germany or France have.
We were warned repeatedly. The National Bed Inquiry in 1993 described a vicious circle of increasing admissions to fewer beds, inadequate investment in community alternatives to hospital meaning less resource for that investment. The Nuffield Trust in 2013 forecast a significant rise in demand for acute beds and the Royal College of Emergency Medicine called for additional capacity.
There are many people in acute beds in any hospital who wouldn’t need to be there if community alternatives were rapidly and readily available to help people leave hospital or avoid the need for admission. But since 2010 we have seen an estimated 17 per cent reduction in social care funding, with around half a million fewer adults receiving home care and no increase in care home capacity, despite population ageing and rising need. This leaves family members who deliver huge amounts of free unpaid care with nowhere else to turn for support.
We have lost community hospital beds and failed to invest enough in community NHS intermediate care services to support people at home with rehabilitation and recovery. District nursing numbers have fallen dramatically.
The number of medically stable patients stranded in hospital through no fault of their own, awaiting community support on discharge, has risen yearly.
We have seeded a perfect storm with predictable devastation.
Of course, hospitals have their own role in getting more patients home from the “front door”, improving flow through ward beds and tackling delays in assessments and processes. But there isn’t much slack or headroom.
Despite contested government pledges to build 40 new hospitals there won’t be a major increase in beds or the staff to look after them. We need solutions to primary, social and community healthcare – and fast. There weren’t any in last week’s NHS Funding Bill.
You’ll be reading those headlines for years to come otherwise. And not just in winter.
Professor David Oliver Is an NHS consultant in geriatrics and internal medicine, former vice president of the Royal College of Physicians and president of the British Geriatrics Society. He is also a weekly columnist in the British Medical Journal