Projected forward trends of NHS activity and demand offer a sobering perspective on the likelihood of sustainability and transformation partnerships achieving their goals, writes Nigel Edwards
The sustainability and transformation partnerships now being put into action across England are premised on reductions in the amount of hospital activity and the number of hospital beds. But our research has shown how mixed the evidence is for initiatives that set out to shift care out of hospital.
And the authors of a recent study of all STPs by London South Bank University found “little reason to believe that these ambitious reductions in demand and pressure on acute services will be achieved in the timescale proposed”.
In order to get an objective sense of just how big the task STPs have set themselves is, my colleagues and I projected forward trends of activity and demand in a new analysis. We used the Hospital Episodes Statistics database, and ONS projections of the aging and growing population.
The results are stark. Several STPs plan reductions of several hundred beds by 2020. For those which focus on activity, planned reductions in admissions can be as high as 30 per cent. Yet the demographics imply that 11 per cent more bed days would be required by 2020 across England – needing a total of 10,678 additional beds, even if they were run at 100 per cent occupancy.
Many STPs emphasise reducing admissions. There is definitely scope to do so, but further analysis we carried out underlines how difficult it will be to free up space and money
In some areas, the gap is very large indeed. Dorset’s STP commits it to a 20 per cent reduction in hospital beds – yet the demographics suggest it would need 10 per cent more. Kent and Medway plan a 10 per cent reduction in beds against a 12 per cent potential increase.
Can the gap be bridged? The NHS has done it before, working with fewer beds now than it had in 2010 even as activity has risen significantly. But this has not been at the pace that would be required. And it has come alongside systemic failures to deliver A&E and elective waiting times targets, the automatic rationing mechanisms of an overstretched system.
Our analysis also underlines the need for caution about how where such reductions might come from. Many STPs emphasise reducing admissions. There is definitely scope to do so, but further analysis we carried out underlines how difficult it will be to free up space and money.
The data shows that 73 per cent of admitted non-elective medical patients stay for only 1 day or less. These are presumably the patients it is most likely to be possible to care for without admission to hospital. Yet their short stays mean they only use 3 per cent of bed days – so the impact on bed use from diverting them would be very limited. The cost savings may be limited too: many of these patients would require diagnostic tests and investigations whether or not they are formally admitted.
On the other hand, across acute specialties, only 9 per cent of all patients stay more than seven days. However, these patients use over 72 per cent of the total bed days. Forty-one per cent of the total are used by those staying 21 days or more. A significant number of these people could be cared for in other settings that are likely to be better for them, and might be cheaper. This needs to be a priority: but it will not be easy.
There is evidence from the recent Intermediate Care Audit that the services they could go to may not be available. It is not always clear whether STPs are committed to the investment in rehabilitation and home care that would make caring for these often old and frail patients elsewhere feasible.
Even during a period of stretched social and rehabilitative care, though, our data also show that long stays have been falling. This suggests that there are other levers which can and have been pulled. Any opportunity to reduce the bureaucracy and impediments to patient flow associated with assessments and discharge will be worth looking at closely.
The bottom line is that London South Bank University’s study has a point. The reduction in hospital activity on which STPs are premised would require a wide range of often difficult changes all to come off at once. There are hard yards ahead.
Nigel Edwards is chief execuitve of the Nuffield Trust