Why ‘empty hospitals’ headlines mislead

A recurring assertion in sections of mainstream and social media has been that hospitals are literally half empty or strangely quiet. The Daily and Sunday Telegraph, for instance, have repeated these claims on loop.

In turn, say the pundits, this must show that our health service’s response to covid-19 has been overblown, incompetent, based on fearmongering and led to neglect of patients without coronavirus or even those with it who needed admission.

It’s sometimes followed by jibes about NHS staff spending their time doing Tik-Tok dances and stories of personal friends who are doctors and nurses and say they have nothing to do. These opinions seem remarkably resistant to correction by people who actually work in acute hospitals or analysts who understand the real picture. There are also very valid reasons for changing the way we used hospitals during the pandemic, though the armchair critics seem remarkably incurious about them.

The Academy of Medical Royal Colleges warned on 8 October of the risks of rapidly rising covid-19 admissions to hospital. I daresay they too will be accused in some quarters of baseless fearmongering.

Why are people saying this?

Beyond the propaganda, I can see how the “empty hospitals” impression takes hold. We have restricted visiting, shifted a big slice of outpatient activity to phone or online consulting, had to space out investigations and appointments to allow time for cleaning of equipment and to prevent crowded waiting areas. Shops and cafes in lobbies have closed or been scaled down. The casual observer passing through public areas away from wards might assume no work was being done.

Meanwhile, the big publicity machine around the capacity in the rapidly opened Nightingale Hospitals backfired. But they weren’t configured or staffed for elective work, nor for high volume acute work, and with the regular NHS bed base already facing staffing gaps, their emptiness was perhaps just as well.

The figures in England for Quarter 1 (including the peak and tail of the first pandemic wave) had shown midnight bed occupancy in general and acute beds to be 64 per cent as opposed to the 91 per cent plus in the previous quarter or 88 per cent in the corresponding quarter in 2019. For day beds, occupancy dropped from 81 per cent in January to March 2020 to 51 per cent for April to June. HSJ reported that “Our hospitals have four times as many empty beds as normal” – which was factually correct.

This statistic was picked up by OpEd and leader writers by radio hosts and keyboard warriors with an agenda that the pandemic was a “scamdemic” and policy responses were over-reactions. They rarely tried to understand, or explain the reasons for this nor consider the counterfactual – what might have happened if service utilisation and bed occupancy had continued as before. The road not taken was also full of risks. People forget this and try to re-write recent history. So let’s remember March.

Why did we reduce bed occupancy during the first covid-19 surge?

The NHS in England was near the bottom of the developed nations’ league in terms of beds per 1,000 of the population and intensive care beds per 100,000. ICU was often under pressure and struggling for staff and beds. Hospitals were running “hot” at close to capacity daily and not just in winter, with red and black alert status a common feature. Midnight bed occupancy of 90 per cent plus is suboptimal for patient flow, for patient safety and for infection control.

Delayed transfer bed days had hit a record high in 2018 and were just flattening. The National Audit Office and various bed audits had shown large numbers of beds were taken out of commission by those awaiting stepdown care. Overcrowding in accident and emergency was a serious and growing problem and the national four-hour target had not been met since 2015. Elective wait times were rising. With some exceptions, our hospital systems do not separate acute and elective work into different buildings or organisations so that acute surges impact on planned work.

Meanwhile, we had the World Health Organisation declaring a global health emergency, then a pandemic, and modern, well-funded and staffed health systems with more capacity in New York, Italy, Spain and France being overwhelmed and bedless and ICU under extreme pressure both there and then in London.

Modelling suggested that we would have major pandemic surge in March, April and May – which is precisely what did happen. We had very limited access to covid-19 testing, even for sick patients or staff in hospital, let alone for primary and community care. And we were keen to prevent avoidable cross infection of patients while in or at the hospital.

All of our responses must be seen in that context and not in biased and selective retrospect.

How did we change?

In short order, back in March and April, we separated front door hospital streams and ward bed bases into “hot” and “cold” areas in an attempt to separate covid from non-covid patients and avoid cross infection. Although as the pandemic peaked the lack of testing and the rising numbers of admissions made this harder.

Once there were outbreaks on wards not originally designated for covid patients, then some wards or bays had to be closed temporarily or bed numbers reduced to allow spacing.

We also, with additional funds, capacity, responsiveness, national rules and emergency legislation, made efforts to clear patients deemed medically optimised for transfer back home with social care or intermediate healthcare support or into community hospitals or care homes.

And yes, we did have to postpone swathes of elective day case or overnight stay work which we all know has had serious knock-on effects for non-covid-19 patients awaiting investigations or procedures often at considerable personal cost to them. And yes, some patients did stay away from hospitals that were always “open for business” because of fear of contracting covid-19 or their desire to “protect the NHS”.

We also doubled and tripled ICU capacity partly by borrowing staff, space and skills from operating theatres and recovery which are needed to support elective work (which in turn needs ICU capacity for complex postoperative patients).

But imagine if we had not taken those steps and our beds had been overwhelmed, our emergency departments full of people on floors or corridors with ambulances stacked outside and hospital acquired cross infection rampant.

You can guarantee the same critics would have had the knives out.

Where we are now

Right now, hospitals are in a cleft stick. We have targets to increase elective activity and catch up on backlogs, with emergency attendances and admissions heading back towards seasonal norms, discharge rates slowing down as we saturate community capacity and wards or bays suffering temporary closures due to proven or suspected outbreaks.

I understand that acute hospitals in England, on the official measure of bed occupancy, were last week up to 87 per cent – not a long way off the 92 per cent seen last year. NHS Wales’ activity report on 1 October showed overnight occupancy back over 80 per cent, and A&E attendances and admissions rising ever closer to seasonal averages. In England, attendances at Type 1 A&E departments in August were 11 per cent down on August 2019. Since those data were published, It is clear speaking to colleagues around the country that we are heading back into the usual activity and capacity pressures we’d expect in October.

Hospitals are not “half empty” and even if they were, say, a quarter empty, there would be reasons aplenty. Not that some blowhard commentators care to hear them, preferring clickbait and conspiracy theories to constructive commentary.