The Hospital Bed Crisis Preceded the Coronavirus Emergencyand Will Outlive It
Acute NHS hospital consultant David Oliver considers how the COVID-19 pandemic has exposed structural healthcare problems caused by years of neglect and underfunding
In my 31 years as an NHS hospital doctor, 2020 stands out as a year that structural health issues have been more widely understood than ever before.
The Coronavirus pandemic has exposed the endemic problems our health and social care services have faced for years, many of which were hiding in plain sight.
This includes the relentless and growing pressure on a shrinking and short-staffed hospital bed base, which the pandemic has made even more difficult to manage. As a medic working on acute wards looking after hundreds of sick COVID-19 patients, these are my experiences.
Firstly, it’s worth pointing out that the concerted diatribe in select news outlets – suggesting that bed shortages are no big deal and do not require us to reduce viral transmission – are misleading, unhelpful and range from ill-informed to what seems like deliberate misinformation.
I understand that people are upset that Christmas has been ruined for many. I understand the serious and legitimate public concerns about the Government’s inept, passive response to the pandemic, and about the harms to wellbeing, the economy and general freedom because of repeated lockdowns. I know that there are serious concerns about the trade-offs between acute care for patients with COVID-19 and planned care for other groups with conditions such as cancer.
But those arguments should be made on their own terms and not – as some have tried to do – by claiming that COVID-19 is a trivial and over-diagnosed illness or that hospitals and intensive care units are half-empty. Bed pressures and capacity crises are real and are here to stay.
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The Sick Man of Europe
The UK already sits near the bottom of the OECD league table for hospital beds per 1,000 of the population – at around 2.7. Take away the devolved nations and England’s numbers are lower still. They are 25% below the EU average, around half the capacity of France and a third of that in Germany. Overall, bed numbers in England more than halved from 1988 to 2018 even though, during that time, hospital emergency attendances and admissions more than doubled.
Readers may be surprised to learn that we only have around 140,000 beds for an English population of 56 million people, of which barely more than 100,000 are “general and acute beds” – to which acutely sick adults or those needing planned operations might be admitted.
The UK only has 6.6 critical care (sometimes called ‘intensive care’ or ‘ICU’) beds per 100,000 – well down the league table compared to say the US with 34.7, Germany with 29.2, Italy with 12.5, France with 11.6, or Spain with 9.7. Yet, all these countries have seen their ICU beds overwhelmed during the Coronavirus pandemic.
Through March, April and May, a heroic effort – but not a sustainable, long-term solution – saw us nearly double our ICU bed capacity with borrowed staff, borrowed space and occasionally a relaxation of usual nurse-to-patient ratios. This also meant cancelling planned operations that the same staff and space would have been used to support.
NHS hospitals have been running at more than 90% midnight bed occupancy in Autumn, Winter and early Spring during the past five years, with A&E department waiting times growing and overcrowding a risk to patient and staff morale.
Meanwhile, at the back door of the hospital, delayed transfers of care have grown to record levels due to serial social care cuts and a lack of capacity in community services to support people outside hospital.
After mass COVID-19 outbreaks in care homes in the Spring, partly caused by discharges from acute hospitals, the system is now doubly hamstrung. Beds are therefore often occupied by people medically stable enough to leave, but with nowhere to go.
The Health Service Journal reported in October that the country is probably 3,000 beds down on capacity from 2019. And that is before we take into account the impact of COVID-19 on bed availability. At the time of writing, more and more beds in England are being occupied by people with COVID-19, with growing numbers on ICU.
Then we have the problem of COVID-19 outbreaks within hospitals themselves. Sadly, around a quarter of all infections are currently classified as acquired in hospital. If a few patients start testing positive, a whole ward bay or even a whole ward will find itself temporarily closed to new admissions – making it even harder to discharge patients to community facilities. Fewer available beds, still.
This further illustrates the false dichotomy between acutely ill COVID-19 patients and others. With a few notable exceptions in England, treatment for both happens in the very same hospitals. There is a major national push from NHS England to catch up on cancelled and postponed work, but vulnerable people with pre-existing conditions such as cancer are at serious risk if they contract COVID-19 in hospital.
To complete this perfect storm, a bed is no use without staff. The NHS already had among the lowest proportion of doctors and nurses per 1,000 in the OECD, prior to the pandemic. One in eight nursing posts were unfilled. Now, there are thousands of staff sick or self-isolating due to COVID-19. A recent Scottish study showed that clinical staff in COVID-19 wards are between three and six times more likely to become infected and around one in 10 of all patients admitted are frontline health and care workers.
Sometimes the COVID-19 sceptics talk as though hospitals should be bursting at the seams. Unless photos of patients on trolleys in corridors make it onto the news, it seems they will never be convinced that lockdowns, behavioural restrictions or even vaccines should be entertained.
But ask them to entertain the idea of catching COVID-19, requiring an acute bed or intensive care and finding there’s no room at the inn. I’m pretty sure they won’t be quite so complacent, or argue the toss with experienced professionals who do the job every day.
The first wave of the Coronavirus pandemic peaked at a traditionally quieter time for acute care. The second is on top of an annual seasonal crisis – and all NHS workers are suffering the effects.
David Oliver is an experienced NHS acute hospital consultant who has worked on COVID-19 wards throughout the first second waves in 2020 and played a variety of senior roles in health leadership and policy. He writes a weekly column in the ‘British Medical Journal’
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