Financial incentives and technology mean inpatient demand and length of stay are falling, although the population is ageing. In 10 years waiting lists will be a thing of the past say Celine Druilhe and Eric Louie

Financial incentives and technology mean inpatient demand and length of stay are falling, although the population is ageing. In 10 years waiting lists will be a thing of the past say Celine Druilhe and Eric Louie

Ten years from now, will all the beds in your acute trust be occupied?

You may see this as an impertinent question given the UK's ageing population, increasing numbers of patients with complex conditions, and pressures to achieve the target of a maximum 18-week wait. Perhaps the question is irrelevant, given the uncertainty about even short-term priorities.

We would answer no. Anticipating and planning for change in clinical care and technology is critical. We estimate that by 2017, demand for NHS inpatient services in England will have declined by nearly 1 per cent and length of stay will have fallen from seven to 6.5 days. The projections represent nearly 500,000 fewer inpatient spells and 3 million fewer patient days than today.

That means that by 2017, if inpatient provision remains at current levels, there will be over-capacity in acute healthcare provision. This projected decline in demand creates opportunities and challenges for the healthcare sector.

What the future holds

Predicting demand for healthcare services is complex. Forecasts based on population projections would estimate a 10 per cent increase in demand for inpatient services over 10 years, as the population expands and patients gets older and sicker.

Our comapny Sg2's forecast has taken into account other factors affecting use, including socio-cultural considerations, technological and care delivery innovations, shifts in care delivery, and payment.

Socio-cultural considerations include obesity, smoking and diabetes. They affect prevalence of cancer and heart disease. The number of overweight and obese people is rising, while smoking prevalence has fallen steadily over the past two decades.

Innovations in technology and care delivery are powerful drivers of change in healthcare. What affects inpatient use is not just technology, but the pace at which it is adopted.

The location of clinical services will change. For highly resource-intensive care, centralisation of services may become standard. But care for less severe illnesses will move to outpatient settings. Quality, clinical outcomes, convenience and technological differentiation will drive provider selection, as patients exercise their right to choose the location of care. The criteria will also influence PCT commissioning and will lead to reconfiguration of care delivery services.

By providing financial incentives to change behaviour, the structure of provider reimbursement acts as a force for change. Pay structures can enable more flexible commissioning and encourage competition among providers. The experience of countries where case-mix payment was implemented in the past 30 years provides a benchmark for its likely impact in England. In the US, the introduction of case-based reimbursement by the Centres for Medicare and Medicaid Services in 1980 led to a 29 per cent reduction in length of stay by 2000, from seven to five days. It also encouraged care to shift outside hospital settings.

In future, healthcare providers and commissioners will care for patients more efficiently and match the amount of money spent to the severity of the illness. These changes will occur slowly and will probably not affect the number of patients significantly before 2011. Change will not be uniform, but will vary depending on location, care delivery setting and clinical area. Sg2's national forecast projects the following in three key clinical directorates over the next 10 years:

  • a 3 per cent decrease in the use of inpatient cardiovascular services;
  • a 2 per cent decrease in the use of inpatient cancer services;
  • a 5 per cent increase in the use of inpatient orthopaedic services.

Focus on disease management

Patients' cardiovascular conditions are likely to become more complex and to require more costly technologies. Screening, preventive medicines and device therapies will improve clinical outcomes and enable a substantial shift of care to the outpatient setting. Combined with a reduction in length of stay, this will lead to 10 per cent fewer inpatient days by 2017.

The focus will increasingly be on disease management, and prevention of disease complications. Computer tomography angiography is increasingly replacing diagnostic catheterisation in the evaluation of coronary artery disease in low-risk patients. In the longer-term the contrast-enhanced imaging provided by new, more powerful '3T' magnetic resonance imaging technology has the potential to address provocative new questions about the causes of cardiovascular disease by imaging vulnerable plaques in the vascular tree and biochemical changes in the myocardium.

Coronary artery bypass graft procedures will decline over the next 10 years as a result of improvements in the medical management of cholesterol levels, blood pressure, diabetes and the perfection of endovascular intervention. Advances in and expanding applications for interventional implants will offer new opportunities for acute trusts to expand services while extending the lives of cardiac patients. Mechanical circulatory support devices will provide a cardiac surgical approach to treating advanced heart failure.

On the cancer front, as detection occurs earlier, treatment becomes more focused and survivors live longer, a greater range of services will be used over an extended period of time. Cancer is therefore becoming a chronic disease.

Surgical spells will increase, owing to screening and early detection programmes that identify earlier-stage tumours that are more amenable to surgical resection. Emerging medical therapies will be more targeted and efficacious, leading to improved outcomes and fewer complications, as the right patients with the right stage of tumour receive the right combination of therapies.

Inpatient care will be reserved for high acuity patients. Although a population-only forecast predicts 4 per cent growth in inpatient bed days, we project a 12 per cent decline, as minimally invasive surgical resections and oncology procedures shorten length of stay and shift care to the outpatient setting.

Average length of stay will decrease by 10 per cent in the next 10 years. For instance, extensive adoption of laparoscopically assisted colectomy will reduce length of stay and lead to significant savings per spell compared with conventional colectomy. Disease complexity will increasingly drive tumour-specific care and programme specialisation.

Orthopaedic medicine has traditionally been a mainstay of inpatient care, and growth in the baby boomer over-65 population will drive orthopaedic use. Treatable patient populations will expand to include older, sicker patients and younger, healthier patients. But emerging technologies that offer new forms of musculoskeletal care will improve efficiencies and partly offset population-based growth.

Minimally invasive joint replacements and spinal procedures will reduce average length of stay by 10 per cent over 10 years, providing significant savings to trusts that match average length of stay with global best practice. Adoption of these surgical techniques will not be effective unless complemented by a comprehensive approach to patient education, goal-setting and incentivised rehabilitation.

The road ahead

In the immediate future, the pace of systemic change will vary, leading to frustrations in the management of hospitals and, hopefully, only temporary maladjustments. These difficulties should not be underestimated and their resolution will depend on organisational, political and economic factors. But the direction of care delivery is clear and in line with similar historical and current transformations occurring in healthcare systems around the world. They all need to make programmatic choices, focus on chosen areas of expertise, embrace the full cycle of care from illness to wellness, and build excellence through concentration of expertise and volume-based learning.

The implications of Sg2's forecast for NHS acute trusts are threefold. First, efficiency gains will create opportunities to eliminate inpatient waiting lists over the next 10 years.

Second, these gains free resources with which to enhance the scope and value of care, as the decline in inpatient use does not imply that overall demand for healthcare will be reduced. It creates opportunities to shift resources to outpatient or non-acute settings, invest in technological innovation to deliver more efficient and higher quality care, and create clinical programmes around diseases that best meet patient needs.

Third, understanding changes in clinical use makes it possible for all primary, secondary and social care providers to partner and discuss the reconfiguration of services around patients, diseases and resource intensity.

Forecasting clinical services use needs a multi-dimensional approach. Population projections are merely a baseline. The complex interdependence of factors must be taken into account to obtain an in-depth forecast of future clinical use. Understanding the timing, magnitude and impact of technology, payment and care delivery changes on healthcare services demand is essential in defining and preparing for care delivery programmes of the future.

Dr Celine Druilhe and Dr Eric Louie are respectively consultant and vice-president at healthcare research, consulting and education firm Sg2.