The long-awaited national beds inquiry report seems to cater for all tastes. Primary, intermediate, acute. . . you can have it all. Or can you? Laura Donnelly reports

Civil servants tittered at the suggestion that they might have spent the past two years wandering round the country actually totting up the number of beds in hospitals. That really would be silly.

Far more sensible to spend nearly 18 months polishing a document which offers enough options to keep everybody 'cautiously happy' and says fashionable things about intermediate care.

Three cheers, then, for Clive Smee, the Department of Health's chief economic adviser and the report's author, who looked 20 years into the future.

You want more acute beds? You got it. One option offers 35,000 more. And you still get an extra 15,000 intermediate/residential beds and 7,000 intermediate nursing care beds - that comes as standard, whichever model you plump for. But you will have to do without a tasty side-order of extra GPs, district nurses and home helps.

If that's not your style, how about the 'closer to home' option? That way you double the number of district nurse visits, get 10,000 more GPs and up to 131 million more hours of home-helps' time.

Naturally, there are sacrifices - in this case you'll have to cope with a cut in acute beds, 12,000 down on current numbers.

Tough choice? If in doubt, you could pick and mix: the 'maintain' option gets you a handful more acute beds (that's 8,000 in this context) backed up by 6,000 more GPs, up to 10 million more district nurse contacts and 122 million more home-help hours.

The report also highlights short-term projections, with the key one under the media glare being the 4,000 beds (2,000 acute) which will be needed by 2003-04.

But when the government launched a three-month consultation on the national beds inquiry one thing was certain. Intermediate care - trailed by health secretary Alan Milburn in a King's Fund speech earlier this month in terms of cottage hospitals and modern matrons - is where the future lies.

And while it fits neatly into the 'closer to home' package, it is difficult to see how Mr Milburn could bear to look on if a boost to acute beds saw his primary care crusade sidelined.

NHS Confederation policy director Nigel Edwards welcomes the government's 'acknowledgement of the point we have been making that the NHS has significant capacity problems'.

He sees the consultation as 'genuine' - yet flags up Mr Milburn's speech and 'the general policy direc - tion' towards acute care centralisation and primary care development as evidence that the 'closer to home' package is the likely future scenario.

But Mr Edwards warns that recruiting the army of district nurses to run the schemes could prove awkward, with recent figures showing an ageing workforce, in which 47 per cent of district nurses are aged 45 or over.

'There is also the fact that when you take patients out of the hospital, those that remain are likely to need nurses with higher skill levels because of their more acute needs.

'At the same time, out in the community you would also need a higher calibre of staff - because nurses who can work under supervision on the ward will need to be able to work as independent practitioners.

'There are issues around training as well as recruitment.'

Pippa Gough, policy director at the Royal College of Nursing, welcomes the acknowledgement of the value of district nurses - a profession which in recent years has been 'decimated both in terms of morale and recruitment'.

And Dr Michael Dixon, chair of the NHS PCG Alliance, also welcomes further moves to boost primary care. But he does not believe acute beds should be sacrificed.

'We need both. We certainly need some more acute beds.

'We are running at margins that are just too close, and people spend far too much time running around trying to find a bed - which is wasting time.'

But he also highlights the role of 'flexible' alternative schemes in diverting patients from hospital, such as renting beds in residential homes in times of pressure.

Pat Archer-Jones is chief executive of Worcestershire health authority, whose plans to replace acute services at Kidderminster General Hospital with an 'ambulatory care centre' led to a high-profile local campaign of opposition. Ms ArcherJones would be 'alarmed' if Mr Milburn chose to increase acute bed numbers.

'I think it would be a real about-face. The 'closer to home' option is entirely in line with the direction the service is working to.

'We really need to get a bit more balance in the system so we can provide holistic care. We have got a lot of people going into hospital unnecessarily because of the absence of other services. We need to build up those services and contain - and reduce - the number of acute beds in the system.'

That's not how Eastbourne Hospitals trust chief executive Alan Randall sees it. Eastbourne District General Hospital hit the headlines this winter when it hired a freezer lorry as an overflow morgue.

He feels 'a tremendous sigh of relief that at long last there is a recognition that we cannot carry on as we have done in the past, that the service had just gone too far'.

But Mr Randall is unconvinced by the arguments surrounding the 'closer to home' model.

'From the evidence that I have seen, in Worthing and in Eastbourne, there is still a major need for acute hospital care for the elderly.

'I would remain to be convinced that the pressure could be eased on hospitals by additional district nurses and GPs.'

The King's Fund believes the report should be followed by a 'rapid, in-depth audit' of this winter's service pressures, according to a statement issued last week.

This should be followed by 'pilot schemes testing new ways of improving capacity in the NHS', which could include rehabilitation services, preventive care and a greater role for NHS Direct.

But Age Concern policy officer Betty Arrol is alarmed that the DoH has spent two years on a study which has not costed any of its options, and stresses the 'absolutely essential need' to commit to adequate resources.

'They say the reason they haven't done so is because it would make a nonsense of the consultation.

'But the government's own guidance about consultations is that cost is an issue and should be considered.

'I'm also a bit concerned about the assumptions they are working to - which aren't always clear. For example, there is a theory known as 'compressed morbidity' which suggests that as people live longer, their period of ill-health is compressed into a shorter period - so they need less healthcare.

'That is the theory - but then there is a contrary view, that when people live longer they get frailer. It needs more research.'

Shaping the Future NHS: longterm planning for hospitals and related services.

Consultation Document on the Findings of the National Beds Inquiry - supporting analysis .

www.doh.gov.uk