Milburn must seize opportunity to 'reverse' 40-year numbers decline

One of the most intriguing government reports for years is about to be published.

Heavily trailed in health secretary Alan Milburn's King's Fund speech last week, the findings of the national beds inquiry look set to arrest - if not reverse - a 40-year trend in declining NHS bed numbers. It is worth reflecting for a moment on the report's gestation.

Its announcement came out of the blue at the Labour Party conference in September 1998. That inveterate crowd-pleaser, the then health secretary, Frank Dobson, included it in a list of seven initiatives, the others mostly linked to dollops of cash for developments as diverse as renovating casualty departments and improving cancer treatment.

The inquiry was to produce 'clear guidance on the number, mix and use of beds which from now on can be applied each time that the NHS is considering building a new hospital or is reorganising services'. It was to be 'urgent but thorough', reporting in spring 1999. Mr Dobson did not attempt to disguise what had prompted his decision: 'it became clear last winter that in some parts of the country the scale of bed closures had gone too far' - a fact he blamed on the internal market.

So with one swipe Mr Dobson had challenged decades of planning assumptions, and appeared to be suggesting a return to national bed norms, a measure which specified levels of provision by care group and which was abandoned in the early 1980s.

Managers and the other healthcare professions began to marshal evidence to formulate their views.

Whatever the pressures, the service's fewer beds reflected 25 years of better primary care, more day surgery and outpatient clinics, as well as innovations such as hospital-at-home schemes. Against this background, the internal market had been a mere side-show.

But then events took a strange turn. Though it had been billed as a 'national' inquiry, it was in fact an internal Department of Health one. It was never clear who was sitting on it, and no widespread consultation with experts in the field took place. Cynics murmured that internal inquiries tended to come up with whatever conclusions were convenient. Winter came and went - without a notable 'crisis' - but no report appeared in spring. By summer the DoH was admitting the inquiry might not publish its findings until the end of the year.

So what had started as a high-profile headline-grabbing initiative looked set to be buried. Why? Had Mr Dobson forced the DoH to bite off more than it could chew?

The decline in NHS beds began in the late 1950s, but the steep drop took place between 1979 and 1995, when numbers fell by more than 40 per cent - a proportionally greater loss than all other OECD countries except Sweden and Ireland, which left the UK with fewer beds per head of population than anywhere except Turkey, Spain, Portugal and the US. With the highest throughput and shortest length of stay of any OECD country, it was easy to make out a case that the NHS had too few beds. The trouble was that reversing the trend would play havoc with other policy imperatives - not least the private finance initiative, which is busily generating plans for cutting bed numbers further.

It appears to have taken another winter crisis for ministers to decide it was worth resurrecting the potentially embarrassing beds inquiry and turning it to political advantage. We can only speculate on the frantic revisions to the inquiry's report which may have been ordered inside Richmond House in recent weeks.

Mr Milburn left it unclear last week whether the expansion in beds in the 'whole system' would mean more acute beds or whether it would be manifest solely in the new tier of 'intermediate care' he announced. If the latter, he might avoid compromising the NHS's efficient-looking throughput and length of stay statistics.

He would also avoid handing ammunition to the critics of PFI. But he would miss an opportunity to improve quality of care in many a district general hospital throughout the land.