The Royal College of Physicians of Edinburgh (RCPE) endorses the desire to minimise the number of admissions to acute beds that all sectors of society, but especially the elderly, require. The RCPE is keen to state from the outset that no consultant physician wants to admit a patient to hospital unless it is absolutely clinically necessary: pressures on acute beds mean that only patients who are in urgent need of medical care can be admitted.
The latest paper from the King’s Fund suggests that if all primary care trusts could reduce admissions and minimise length of stay to that of the most successful areas then 7000 fewer acute beds would be required in England. They acknowledge that the drivers of variation in performance are complex, including age of patient, level of deprivation and geographical access: areas with well developed integrated service and those with higher levels of an aged population have lower levels of acute hospital bed use. It is suggested that areas with a high number of aged population also have a more developed integrated service.
It is for these very reasons that caution is required in interpreting this report. If acute hospital beds are reduced without a concomitant development of integrated services, patients will be potentially worse off. There is evidence of an inexorable rise in acute hospital admissions especially to acute medical units with increasing weight of expectation of what medical care can provide. We feel in these circumstances that it is vital that the promotion of admissions avoidance, particularly of older people, does not restrict appropriate access to best care at times of medical need.
Boarding of patients is rife within the acute hospital sector and this itself is associated with a range of well-evidenced adverse outcomes for patients, including increased death rates, length of stay, re-admission and the development of medical complicationsi. This problem would be exacerbated with even fewer beds being available and the pressure to achieve the elective workstream would increase with more surgical procedures having to be postponed due to a lack of beds.
The RCPE conducted a survey in May 2012 to obtain a snapshot of senior doctors’ practical ongoing experiences of boarding in Scottish hospitals. Key findings included 80% of respondents reported that boarding is now experienced all year round in Scottish hospitals (with 50% reporting that boarding had taken place during the last week in May); 71% of respondents believe boarding levels in Scotland are high and increasing, at a time when the Scottish Government has been reducing the number of acute beds in Scotland; 99% believe boarding has a very negative or negative effect on the quality of patient care, 95% a very negative or negative effect on the length of patient stay, 68% a very negative or negative effect on death rates and 68% a very negative or negative effect on rates of patient re-admission to hospital.
It is vital that the significant investment necessary to provide integrated services must be accurately calculated so that if the King’s Fund report is to be implemented, adequate resource is made available to enable this development prior to closure of acute hospital beds. This would allow proper consideration of the most appropriate use of the resource available to the health sector to deliver the services that are required in disparate localities.
We support shifting care closer to home; however the ambition to reduce reliance on the acute sector must not be pursued to the detriment of quality of patient care.
i Spivrulis, P.C., Da Silva, J.A., Jacobs, I.G. et al. (2006). The association between hospital overcrowding and mortality amongst patients admitted via Western Australian emergency departments. Med J Aust, 184(5); 208-212.