The reasons behind the problems at trusts in winter are complex, overlapping and numerous. One issue that often lies at the heart of the problem is the increasingly high proportion of beds that are occupied during the colder months.
94.9% of general and acute beds were full during January 2018, and in February that figure rose to 95.1%.
As a general guideline, evidence suggests that to ensure safe patient care occupancy should ideally not exceed 85%1, while NHS Improvement has said that above 92%, the deterioration in A&E performance begins to accelerate.2
Furthermore, high bed occupancy leads to issues across trusts, and is often a decisive factor in the decision to cancel operations (for example last winter, which saw tens of thousands of operations cancelled with little warning).
In last winter’s situational reports (an NHS England dataset which indicates the level of pressures on secondary care), between the last week of November and the first week of March, 80 trusts (of 137) spent at least half of that period at 92% occupancy or more. Only five never exceed 92%.
It is clear that the NHS no longer has the bed capacity to cope with high levels of demand in winter.
How many beds are needed in England?
Using bed occupancy and availability data from previous winters, the BMA has calculated how many additional general and acute beds each trust would have needed to meet certain bed occupancy thresholds.
For example, on 20 February 2018 (the day that saw the highest occupancy), trusts would have required an additional 4,809 beds to have achieved under 92% bed occupancy across England. In order to have achieved 85%, an additional 13,066 beds would have been needed.
The more achievable goal of 92% would still have required almost 5,000 more beds, and in the last two winters, the addition of 5,000 beds would have reduced occupancy by 4.6% in 2017/18 and 5% in 2016/1745, in both cases. It is also worth noting that 5,000 is also the number of extra beds endorsed by the Royal College of Emergency Medicine.6
Whilst 85% bed occupancy remains the long-term goal, in the short-term the BMA believes the NHS needs 5,000 more beds than last winter if the more realistic goal of 92% is to be achieved, and if patient safety and A&E performance are not to be severely compromised in the 2018/19 winter. This is in addition to the 2,500 – 5,000 escalation beds normally opened during winter, so could represent as many as 10,000 additional beds on top of the NHS’ core bed stock.
In the longer term, even with a greater emphasis on primary and community care, a year-round 85% occupancy figure (as recommended by the BMA and a number of royal colleges) will only be achievable with a substantial increase to the number of beds in England. Therefore, a long-term bed strategy should be implemented with a view to reintroducing a sufficient number of beds across England to the point where 85% bed occupancy can be reached.
How many beds are needed in different parts of England
Using trust-level data, the BMA has also calculated approximate numbers of beds required by different regions of England.7
|East of England
||Yorkshire and The Humber
Are trusts attempting to address the possible shortfall?
Earlier this year the BMA sent an FOI (freedom of information) request to 135 trusts asking for clarification on their winter planning, including how many additional beds they believed they would need this winter, and whether they would be increasing their bed stock accordingly. Of the 135 trusts we contacted, just under two thirds responded.
The responses varied significantly, with some trusts suggesting that they could need as many as 150 beds, while others said that they did not expect to need any additional beds at all. A small number of trusts (7) were explicit about their plans to make no additions to their bed stock – citing reasons including staff shortages, space constraints and lack of funding.
However, it was clear from the majority of other responses that where trusts are planning winter bed increases these are fairly modest in scale and are unlikely to meet the levels of demand this winter if the BMA’s projections are accurate.
Of the trusts which replied to say that they would not be increasing the number of beds to match the projected shortfall, almost all suggested that other measures (e.g. length of stay reduction, improved patient flow) would be sufficient to reduce demand to manageable levels.
Though some hospitals are increasing their bed stock, the results of the FOI would indicate that a bed strategy is only being implemented where sufficient funding has been made available, and that reductions in admissions and length of stay (which are often both contingent on uncontrollable factors such as weather and flu) form a much larger part of winter pressures contingency planning.
- With winter fast approaching, it seems unlikely that any trust will be able to substantially increase its number of available beds at this stage. However, those trusts with the greatest need should be supported to address their shortfall as much as possible in the time that remains before winter pressures become more substantial.
- Greater transparency about winter pressures is needed. Data publication often changes year-to-year which severely affects comparability. NHS England should resume publishing the OPEL (operating pressure escalation levels framework) data as part of the Winter Situational Reports dataset (which was available in 2017 but not 2018) and should ensure that data gathering and publication is consistent every year.
- NHS England must set out clear plans of how occupancy levels will reach acceptable levels over the coming years in its forthcoming Long Term Plan, and the government must back NHS England with sufficient resources to achieve this.
More information: NHS bed facts and figures
1. A safe bed occupancy figure is contingent on the clinical setting (eg an urgent care setting will require a lower occupancy figure than a ward catering for patients undergoing planned procedures) but broadly speaking, 85% represents the benchmark for patient safety, and it is inadvisable for bed occupancy to regularly exceed that figure.
2. NHS Improvement, review of winter 2017/18
4. Percentage points
5. Winter in this context refers to the period covered by the relevant data, which traditionally starts publication in late November and ends in early March
6. NHS Improvement, review of winter 2017/18
7. Please note, these have been calculated differently to the national figures and so the total number of beds is slightly higher than the national ask. The pan-England ask is partially based on the bed shortfall on the busiest day in February, but some trusts had much higher occupancy on other days that week. In these cases, we have used the figures from the busier days. The regions have been devised using STP boundaries, with STPs combined to form larger regions. The figures are rounded.
Read 2017/18 report
Download the full report for the whole of the UK published in February 2017.
State of the health system - Beds in the NHS (PDF)
As part of our ongoing work evaluating pressures in the NHS, the BMA is publishing monthly analysis of a number of key indicators, including those directly related to winter pressures.
Read our analysis of pressure points in the NHS
As part of our analysis of the winter pressures we have calculated the future trends and projections for 2018/19.