Sir John Bourn, head of the National Audit Office, reported to Parliament today that many NHS hospitals have made important improvements in the way they admit and discharge patients, and manage their bed stock. But there are significant variations in performance, and some trusts could do more to reduce the number of cancelled operations and delays in discharging people from hospital.
In 1998-99, around six million patients in England stayed at least one night in NHS hospitals, a record level, and two thirds were emergency cases. This record was achieved despite a fall in the number of general and acute hospital beds in recent years, made possible by changes in patient care practices. But there are signs of significant pressures, with the number of operations cancelled for non-medical reasons on the day of admission reaching record levels, and around 20 per cent of emergency patients waiting longer for admission than the Patient’s Charter standard of two hours. In addition, 35 per cent of hospitals reported facing times when demand for beds exceeds availability at least once a day, and delays in discharge from hospital affect an average of nearly 6,000 people over 75, costing trusts about £1 million a day. Significant numbers of patients were waiting for an outpatient consultation in excess of the Charter standard.
In response to these pressures, Sir John found that many NHS hospitals are making considerable efforts to improve the way they admit and discharge patients, and manage their bed stock. In particular:
- almost all hospital Accident and Emergency departments will have an admissions unit or observation ward by July 2000 to reduce patient waiting times, to accommodate patients with medical emergencies more comfortably, and to reduce the overall level of emergency admissions;
- there has been a 20 per cent increase in two years in the number of trusts with bed managers, whose role is to ensure patients are placed promptly in appropriate beds;
- almost all hospitals have strategies to respond to short-term bed shortages; and
- around three quarters of trusts now employ discharge co-ordinators to help overcome obstacles to patients being discharged when ready, compared to around 40 per cent in 1997.
But, Sir John found that bed unavailability is the most common cause of cancelled operations, with beds occupied by new emergency cases or patients whose discharge has been delayed. He also found that very few hospitals have systems providing up to date information to monitor and coordinate key resources such as beds and theatre time, and that in over 90 per cent of trusts, bed managers obtain information on bed availability only through physical inspection and telephoning wards several times a day. He also found that more than a quarter of trusts did not begin to consider discharge needs of patients as early as they could.
Based on findings from the first comprehensive survey of hospital practices, Sir John highlights 20 areas where more NHS acute trusts could follow the lead of others. In particular, he concludes that more trusts could assess patients before they are admitted; admit greater numbers of patients on the same day as their operation; and more could begin liaison earlier with other care agencies to plan patient discharge. In addition, Sir John points to three areas where across-the board improvements are necessary. These are in:
- developing significantly improved information systems to allow hospitals to monitor and plan better the use of key resources such as beds and theatre time;
- enhancing the role of bed managers to move away from crisis management, and make better use of their knowledge to plan admissions and think strategically about the use of beds; and
- improving co-ordination between different professional groups within hospitals, and between hospitals and other external care agencies such as social services, to minimise the risk of delays in discharging those ready to leave hospital.