Health Service Focus

Reducing variation in acute bed use

Candace Imison, deputy director of policy at health think tank The King’s Fund, has written a report on the use of emergency hospital beds and the significant variation evident in this. Here, she speaks to NHE about the report and what can be done to reduce variation.

Hospital use by elderly patients is an increasingly hot topic in the NHS, with a prevailing attitude that A&E is not the best place for them to be – and too often where they end up.

But new evidence suggests that trusts in areas with higher numbers of older people are managing to meet their additional needs, and in fact have some of the lowest rates of emergency bed use across the NHS.

NHE talked to Candace Imison, deputy policy director at The King’s Fund and author of a new report which highlights the amount of variation evident in acute care across the country.

Discussing the factors behind variation in emergency hospital bed use, Imison said that although the biggest driver is clearly age, access to healthcare is also fundamental.

Access and integration

It was this, rather than the expected link between bed use and spend on social care, or community beds, that was found to be more significant. People in rural settings, with worse access, were found to use acute beds less.

Imison said: “The surprising thing for us was that we were partly expecting to see some clear links between use of acute beds and say numbers of community beds, or numbers of GPs or types of GP practices, or the spend on social care – and in those areas we couldn’t see a clear link.”

All of the ten lowest uses were found to be in a rural context, and had done a lot with joint working and integrated care – something Imison said needed further exploration to understand how it had been achieved.

It seems that location is more significant in terms of emergency bed use, and how different services relate to each other is the most critical factor of all – with the degree of coordination across different services as important as the actual presence of the services.

Imison explained: “If you just have piecemeal initiatives, they tend to have rather limited impact, not least because often people like GPs aren’t even aware that they exist. You really do need a concerted effort across the system to make things work.”

Prioritising elderly demand

Despite media alarmism that the ageing population is placing an undue strain on the NHS, which it is failing to respond to effectively, The King’s Fund found evidence that implied the areas with more elderly people had lower use of emergency beds. She said: “That was the other striking and novel finding in our work: that areas that did have a higher percentage of older people also seemed to have a lower use per older person of acute beds.

“Our hypothesis is that these are areas where, because they have a higher percentage of older people, they have had to prioritise their needs and worked hard at trying to address their needs – and that is seen in the lower use of acute beds.”

This is something the NHS must pay more attention to, she recommended, to create better services more suited to elderly patients’ needs. There is a growing awareness of this need, and the need for greater integration in the health service, as Imison said: “I think there is a really strong understanding of that but it’s still easier said than done.”

She added that leaders of NHS organisations will need to work together with clear joint strategies to tackle the issue, and that the new CCGs offer a place for such work to take place.

Balancing act

It’s imperative that trusts see this research as a call to balance variation of acute bed use, not just a blanket call to reduce beds, Imison cautioned.

“It needs to be part of a joint strategy. This isn’t something where you just shut beds and think you just pocket the savings; this is about supporting a transfer of resources from hospital to community.”

The King’s Fund has recommended a joint strategic approach to achieve this, balancing bed reductions in acute trusts with investment in the appropriate community services.

And Imison accepts that doing so will be no easy task.

“It is clearly a difficult time for people to be doing this when there is overall pressure on resources. I don’t think anyone underestimates the challenge of doing this but overall, the quality gains to patients are very considerable.”

The benefits also include a model of care which is “intuitively more sustainable in the longer term”, she said.

Imison concluded: “The way people work together is key: we need system leadership to support that.”

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