Reform Scotland

Should we be worried about the number of hospital beds? – Gordon Hector

A wee theme has emerged during the ambulance crisis: that it comes after years of cutting bed numbers, and therefore the NHS isn’t ready. This claim popped up earlier in summer, and then again last week.

It’s true, but only half the story. Here’s why.

An NHS bed exists in time and space: technically we count the number of days a bed is available and staffed.

Why does this matter? Because about two-thirds of the drop in ‘beds’ were in surgical specialties. Over the past 20 years, surgery has become much more efficient. Procedures which would have previously required a couple of days in hospital will now be a morning trip in. This is a *time* saving and is unequivocally a good thing: people can be seen more quickly, recover better and faster, require less risky types of anaesthetic, and avoid introducing or picking up bugs on wards.

And it means that across the system, we can achieve better outcomes with far fewer bed days.

There’s also the argument that concentrating some types of care makes it safer. Crudely, a surgeon who does 30 procedures a week is, all else being equal, going to be better than one doing 5. When you create clusters of experience, you can also intensify research, create better progression for ambitious doctors, and reduce the overall cost of care by creating economies of scale for buildings, equipment and salaries. This points, on the whole, to larger intensively-run centres which replace networks of smaller, less intensively-run hospitals – which means fewer beds overall. That’s what the big hospitals in Edinburgh and Glasgow are about.

Other countries have had similar policies – in fact, I remember a conference in about 2015 where a panel agreed that Germany’s relatively high bed count was a sign of a badly-run system. The punchline was that on beds, the UK was more efficient than the Germans.

You can debate the trade-offs of this approach: it means centralisation. You can call it unwise, in retrospect, to not also increase capacity at the same time, or to prepare for a moment like this year. As Paul Gray wrote earlier this week, the system is now overwhelmed and ‘radical surgery’ is necessary – and there are some stand-out examples of radically decentralised health and care systems we could look to.

But you can’t claim that reducing beds is brazen mismanagement, a conspiracy, or even really a cut. It was driven by a realistic clinical and managerial logic. And it was a response to the things we have required of the NHS: to offer more care, more safely, more efficiently.

Unfortunately, the pandemic is different. After years of trying to make more care preventative and out-of-hospital, we suddenly had to deal with immediate, hospital-heavy care.

This means that the right number of beds in the old world might not be the right number in the new.

This frames the big question for what comes next in health – and indeed other public services, and even the economy. The past ten years have been about more from less. We are now living through shocks that show us retaining capacity to respond and flex might be just as important.

There’s no easy answer but we can at least frame the question for future choices: what do we want – efficiency? Or resilience?

It was obvious before the pandemic which we prioritised. Now it’s far less clear. And less clear still, if the answer is ‘both efficiency and resilience’, how we pay for it and what kind of system will deliver it. Covid-19’s impact on healthcare policy has a long way to go yet.

Gordon Hector is a policy consultant and former Director of Policy and Strategy for the Scottish Conservatives