England

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Bed numbers in England by STP

The winter of 2017/18 has been widely acknowledged as the most pressurised in the history of the NHS in England, with A&E departments struggling to cope in the face of enormous demand and limited capacity. This intense pressure has highlighted how important bed capacity is to the ability of the NHS to withstand peaks in demand, and the risk that reductions in that capacity may present.

This research explores the relationship between bed numbers and key NHS targets such as A&E waiting times, by:

  • producing a historical analysis of how bed numbers have changed at STP footprint level (the overall geographical area of each STP), looking at variation in how some areas have chosen to increase or cut bed numbers in recent years in the context of national changes in bed numbers between 2014/15 (prior to the creation of STPs themselves) and 2017/18
  • assessing the relationship between changes in bed numbers and performance against national targets, such as A&E waiting times
  • analysing what assessments STPs have made of bed capacity in their locality and what plans they have for the future, based on BMA freedom of information (FOI) requests

Our research looks specifically at bed numbers across the NHS Trusts in each of the 44 STP footprints between 2014/15, when the FYFV, was launched, and 2017/18. In conjunction with this data analysis we also submitted FOI requests to each STP, requesting details of both their assessment of bed capacity in their footprint and of any plans they may have to reduce bed numbers.

 

Key findings

Our analysis has revealed that:

  • beds have reduced by an average of 140 per STP footprint since 2014/15 – a fall of over 6000 at a national level – bed numbers have decreased in 29 of 44 STP footprints since 2014/15
  • the largest decrease in bed numbers amongst STP footprints was 21%, whilst the largest increase was 22%
  • the 10 STP footprints that experienced the largest reduction in bed numbers also saw the most rapid deterioration in performance
  • all but 3 STPs have said they have no plans to reduce bed numbers, in many cases showing significant divergence from their original plans
  • several STPs appeared not to have carried out any analysis of the bed capacity across their health system
  • projections suggest that by 2019/20, there will be approximately 125,000 beds in the NHS

 

Our recommendations

  • the Government should report on bed numbers on a regular basis at an STP level, making this information easily accessible to the public
  • that the proper resources, planning, and time are dedicated to enhancing care and capacity in the community, if they are expected to absorb greater demand
  • all STPs should be required to assess their bed needs over 5-10 years, publishing their findings
  • as further cuts to beds are likely to exacerbate pressures, which have already reached historic highs, no further bed cuts should be planned until key targets can be reliably met and sufficient capacity within the community is established
  • as part of any future long-term plan for health and social care services, the government should prioritise restoring bed capacity in the NHS to a level considered appropriate by clinicians

 

All STPs

 

Download the report

 

  • Background

    In March 2016, England was divided into 44 geographic STP footprints, each of which brought together hospitals, CCGs, GPs, local authorities and other health and care providers with the objective of producing collective plans for the future of health and care services in their area. STPs are intended to deliver the NHS FYFV and, importantly, to achieve financial balance by 2020.

    Although STPs and their footprints are central to NHS England’s vision for the future of the NHS, data reporting and analysis has been slow to adapt to this. Performance data has only recently been provided at STP footprint level and, as outlined in this report, bed data is still only available for individual Trusts. Therefore, given the importance of STP footprints, it is imperative that data is provided and examined at this level, for both before and after their creation.

    In their initial plans, a significant number of STPs proposed reducing bed numbers and shifting care into the community and general practice as a means of achieving financial balance and delivering the FYFV. This was highlighted in the BMA report Delivery Costs Extra, as were our strong concerns about any loss of beds without significant prior investment in community care, and the evidence base for this approach generating financial savings.

    The BMA has also been critical of the way the STP programme has developed nationally. One of our primary criticisms has been of the severe lack of transparency surrounding the process and the absence of consistent clinical and public engagement in many areas. This has been a particularly acute problem in respect of planned bed closures and service reconfiguration.

    Although bed closures are subject to rules on public consultation, and NHS bodies are now required by NHS England to pass a test for any proposed bed cuts in respect of their impact on patient care, there remains significant confusion in many areas regarding bed planning at an STP level.

    The lack of substantive public engagement by many STPs on their plans, even in cases where proposed bed reductions are no longer being pursued, has meant that many doctors, NHS staff, and the public remain concerned and uncertain about the implications those plans may have. As a result, it is important that future plans STPs might have in relation to bed numbers are transparent and made public.

  • Data

    Beds in the NHS

    It is a well-established fact that the NHS has cut a substantial number of beds in recent years. The 2017 BMA report, State of the health system – Beds in the NHS, examined the implications of and reasons behind cuts to beds. The report found that reductions in the length of inpatient stays, better primary care and a general shift towards preventative and community care mean that fewer overnight beds are needed, but that hospital beds remain a core component of the health system and the recent decline in bed numbers remains a major cause for concern.

    Since 2010, the number of overnight beds in the NHS in England has decreased by over 14,000, in which time the average bed occupancy figure has increased by 3% (in the most recent data, occupancy of all beds was 88.4%).

    Figure 1: Available beds and bed occupancy

    STP and Bed numbers in england ARM 

    The available data also indicates that the rate of bed cuts is accelerating. Between 2011/12 and 2013/14, the NHS cut 3,400 beds, or 2.5% of the available bed stock; between 2013/14 and 2017/18, 6,200 beds (4.6%) were cut.b Using an average rate of decline from the past eight years, projections suggest that by 2019/20, there will be just over 125,000 beds in the NHS in England. With most trusts approaching (or even exceeding) occupancy figures of 95% for much of the most recent winter, it is increasingly hard to see how hospitals can be expected to cope with seasonal increases in demand as many of them enter each new winter with fewer beds than they had the previous year.

    Using historic data and STP footprint boundaries, we calculated which parts of England saw the most substantial cuts. Our analysis has examined changes to bed numbers across individual STP footprints, collating data from the individual NHS trusts within those areas in order to present a system-wide figure.

  • Findings

    Across all 44 STP footprints, the largest reduction was 1,282 beds, whilst in a few cases the number of beds rose (the largest increase was 302 beds). On average, 140 beds have been lost per STP footprint.

    Figure 2: Top and bottom 10 STPs by proportional changes in bed numbers

    Lincolnshire   -21.0% Dorset  21.7%
    South East London  -18.0% Cornwall and the Isles of Scilly  14.5%
    Leicester, Leicestershire and Rutland   -17.6% Milton Keynes, Bedfordshire and Luton  9.0%
    Somerset  -15.8% Birmingham and Solihull   6.2%
    Greater Manchester  -15.4% Frimley Health  5.7%
    South Yorkshire and Bassetlaw  -15.1% Northamptonshire   5.1%
    Staffordshire   -13.5% South West London   4.6%
    Hertfordshire and West Essex   -11.6% Sussex and East Surrey   3.0%
    Mid and South Essex  -9.3% Bristol, North Somerset and South Gloucestershire   2.9%
    The Black Country   -8.9% Suffolk and North-East Essex  2.3%

     

    The data shows significant variation across England in the extent of cuts to beds; Lincolnshire saw a decrease of 21% in its number of beds whilst Dorset saw its bed stock increase by almost 22%. Across the whole country, the average decrease was 3.6%. 14 STP footprints increased their bed stock (by an average of 5.7%) against 30 that saw decreases (by an average of 7.9%).

  • Targets

    An increase in pressures and demand between Q4 of 2014/15 and Q4 of 2017/18 is consistent across almost all STP footprints. In this period, the average increases per STP footprint in attendances at A&E and emergency admissions were 9% and 12% respectively, while performance against the four-hour wait deteriorated from an average of 91.3% to 84.6%.

    Trolley waits of four or more hours increased from an average of 2,583 to 5,131 per STP footprint, while twelve-hour trolley waits went up from 22 to 52. There are several notable differences in performance between STP footprints that have either gained or lost beds. Performance has deteriorated in the latter at a faster rate, though those that have gained beds have seen demand increase at a faster rate.

    In STP footprints that gained beds, the proportion of patients seen, discharged or admitted within four hours fell by 5.9%. In those that lost beds, the figure fell by 8.0%. Similarly, even after the exclusion of two major outliers,d four-hour trolley waits increased by 84.3% in footprints that gained beds compared with 106.3% at those that lost them.

    Figure 3

    STP and Bed numbers in england ARM

    Whilst pressures and performance are determined by a much larger number of overlapping issues, beds remain an important facet of healthcare delivery. The only period of the year in which the number of beds consistently increases (winter) sees the highest levels of pressure, but demand and activity increase every year (attendances at A&E increased by an average of 1.7% per year between 2011 and 2017, while emergency admissions increased by 2.6% per year); in the same period, the number of beds fell by almost 10,000, and bed occupancy increased to unprecedented levels.

    The Nuffield Trust has calculated that based on increases in activity and population size, the NHS is liable to require an additional 10,700 beds in the coming years, rather than further reductions (a figure which also imagines trusts running at 100% occupancy, which would be impossible in practical terms, so the real number is liable to be even higher).11 Clearly, then, bed numbers continue to play a vital role in ensuring that patients have timely and safe access to quality care.

  • STPs: Beds and future plans

    Our 2017 report, Delivery Costs Extra, found that almost all STP plans prioritised improving prevention and shifting care into the community. In many cases this was in conjunction with plans to reform the provision of acute and community hospital services, including reductions in bed numbers.

    Most plans were also explicit that these changes were intended to not only reduce hospital activity, but to also deliver financial savings – despite significant evidence challenging the concept that shifting care into the community generates major savings.

    Therefore, alongside our data analysis, we also submitted FOI requests to all 44 STPs, to establish what assessment each had made of its overall bed capacity and whether they have any current plans to reduce it in the future. Specifically, we requested the following information:

    • the number of available overnight and day beds at trusts within their footprint counted as part of the STP’s planning
    • the number of available community beds
    • any plans to reduce or increase the number of beds within the footprint by 2020/21
    • any reviews, consultations or impact assessments pertaining to changes in bed numbers

    Of the 44, 32 responded directly to the request. Of those 32, all but 11 argued that there were grounds to exempt the information as the number of beds within STP footprints could be calculated using NHS England data. Of the 11 that did respond with bed numbers, just three discussed plans to change the number of beds within their footprint. The vast majority of STPs responded that there were no plans to change the number of beds at trusts as part of the local plan.

    Although several STPs provided us with detailed breakdowns of their current bed stock, as well as plans for further changes to bed numbers, in most cases STPs provided neither. Given the nature and purpose of STPs, and the fact that many plans involve major changes and reconfigurations of local services, proper engagement and transparency is essential.

    However, most STPs directed us to an NHS England dataset that does not include an STP breakdown and required a separate exercise to match trusts to their relevant footprint in order to calculate the number of beds within an STP. Moreover, whilst A&E data is now published at STP level, most other datasets are published only at national and trust level, a situation which should be addressed by NHS England as soon as possible.

    Secondly a number of STPs responded that they had not yet assessed the number of beds within their footprint, or within each of their constituent Trusts. These included the West Yorkshire and Harrogate STP and the Frimley Health and Care STP, which was rated ‘outstanding’ in the NHS England progress dashboard. The BMA remains concerned that many STPs, including the most advanced, are unable to share an assessment of their local health assets.

    Thirdly, whilst several STPs clarified that local plans did include bed closures, and offered information on the extent and underlying rationale for these cuts, the majority suggested that there were no plans to close beds at trusts in the footprint.

    However, as clarified in this report, in 29 of the 44 STP footprints bed numbers have reduced over the last three years, in some cases very dramatically, and the likelihood that there are no further closures to come seems extremely slim. Several STPs also have plans to conduct reviews of their acute services which, depending on their outcome, may generate plans for future reductions in bed numbers within certain STPs.

  • STPs and community care

    As noted above, many STP plans included references to bed cuts on the basis of shifting care into the community. In this context it is important to be clear that reducing bed numbers is not inherently a problem in all cases. However, it is vital that any reductions in bed numbers are evidence-based and subject to thorough review, impact assessment, and engagement with clinicians and the public. It is also essential that any plan to transition care from hospitals to community and GP settings is properly funded and that those services can develop to safe levels before hospital capacity is cut.

    This evidence, engagement and investment has not been forthcoming. Additionally, despite calls from the Kings Fund for STPs to revisit their plans for community care and for a national strategy for community care,13 NHS England has since abandoned plans for a ‘Five Year Forward View for Community Care’.14 This decision has been criticised by Bill Kirkup, author of the recent report into the state of care at Liverpool Community Health Trust, who has argued that efforts to sustain growing workloads with reduced capacity presents a genuine risk to patient safety and quality of care.

    There are, therefore, significant questions surrounding the basis upon which many STPs built their initial plans for reconfiguration, and the current capacity of alternative services to compensate for any further reductions in hospital beds. If STPs continue on the current trajectory of decline in bed numbers, let alone proceed with further cuts, there must be a clear strategy for doing so and sufficient time and resources provided to community and primary care to compensate for the increased demand this will generate.

  • Conclusion

    The English NHS is enduring the most intense period of pressure in its history, amid underfunding, system transformation, and, as our analysis shows, a significant lack of capacity to handle growing demand.

    Our analysis of bed numbers within STP footprints reveals that there is an historic and ongoing decline in bed numbers across England, and that this has continued within the majority of STP footprints. Moreover, we have found that where that decline occurred most quickly, performance also deteriorated at the fastest pace.

    In addition, our FOI requests to each of the 44 STPs revealed a lack of understanding within STPs themselves of the total number of beds available in their area, and that, in contrast to the proposals within many of the initial STP plans, very few have active plans to reduce bed numbers. While the shift in focus away from bed cuts is welcome, the lack of willingness, or ability, to share details of bed numbers in many STPs is seriously concerning and underscores the BMA’s ongoing concern regarding the transparency of STPs.

    Considering our findings, we have four recommendations that we believe need to be followed to ensure that pressures on the NHS are reduced, that patients can access services swiftly, and that doctors are able to provide the best quality of care possible. These are:

    • the Government should report on bed numbers on a regular basis at an STP level, making this information easily accessible to the public
    • that the proper resources, planning, and time are dedicated to enhancing care and capacity in the community, if they are expected to absorb greater demand
    • all STPs should be required to assess their bed needs over 5-10 years, publishing their findings
    • as further cuts to beds are likely to exacerbate pressures, which have already reached historic highs, no further bed cuts should be planned until key targets can be reliably met and sufficient capacity within the community is established
    • as part of any future long-term plan for health and social care services, the government should prioritise restoring bed capacity in the NHS to a level considered appropriate by clinicians