Asking the wrong question about bed occupancy doesn't help fix the problem

Campaigning for the NHS to have more beds is a distraction from searching for the most effective way to improve the flow of patients through hospitals. The right question is "which actions could we take now to improve flow". More beds is a bad answer to that question. Worse, the metrics we use actively distract the system from looking for the right answer. The NHS desperately needs to do better.

Bed occupancy in the English NHS has reached new record levels at the end of 2018 and this has, yet again, led to calls for the NHS to increase the number of beds (see this in the BMJ, this from the BMA and this in the Independent). The argument is that England has few beds relative to peer group countries and has been cutting them over the last two decades. So, reversing that trend would ease winter pressures, increase hospital safety and reduce long waits in A&E.

But there is a problem with this interminable debate: the answer campaigners propose assumes the wrong question has been asked. And it naively assumes that the solution would have the intended effect. Worse, it distracts from any proper analysis of the problem and the search for other effective solutions.

It also constantly repeats dubious statistics about what works which also distract from any useful understanding of what the problem is.

The right question to ask is "what intervention would most increase the capacity of hospitals to treat patients quickly and effectively". And "more beds" is far from being a useful answer to that question.

So here are a few thoughts about why we are having the wrong debate and what we can do about it.

You can't add more beds quickly

The simple solution "lets have more beds" sounds easy but isn't. Though not every campaigner stops after demanding more beds, many do. But this is just passing the buck and not actually helping much.

The problem isn't that the NHS doesn't have enough beds. The problem is it doesn't have enough staff to man the beds at currently accepted levels of safe staffing and it doesn't want to relax the rules about safe staffing. You can only overcome the staffing problem if you can recruit more staff. But, to paraphrase Dido Harding, the problem is that not enough people want to work for the NHS.

To get more staff you need a source of qualified recruits (Brexit isn't helping with that) and a working environment that doesn't drive them away. And you can't improve the working environment without understanding why it is currently unattractive. Which implies fixing other problems before you can recruit the staff needed to man the extra beds. But every time the call is made for more beds, the system and commentators on it are distracted from the search for those other problems.

Campaigning for more beds is a little like a doctor whose primary advice to patients is to be less sick: it almost sounds plausible but does fuck all to fix the problem.

Adding more beds doesn't necessarily fix the problem

The idea that adding more beds would automatically fix the problem is naive. It hides a deeply false assumption about how admissions and discharges work in a real hospital.

The intuition that for a given sick patient there is a fixed number of days they need to spend in a bed is plain wrong. But the idea that more beds would lead to reduced occupancy implicitly assumes this is true. We know it isn't.

There are several different lines of evidence that point to this intuition being wrong.

The first is empirical evidence about what happens when more beds are added to a system. The Modernisation Agency had interesting evidence about this in the early 2000s. They showed clear evidence that while adding extra beds lowers the bed utilisation in the short term, the benefit disappears quickly because the length of stay rises in the medium term eliminating the benefit.

And it is easy to see why if you know how discharge processes work in the NHS. To get a patient out of a bed you have to coordinate several activities: they have to be assessed as fit to go home; they have to get their take home medicines; they have to have transport; discharge letters have to be written… But these activities are often not coordinated and unnecessary delays are common. Where there are many free beds and few problems admitting new patients there is little incentive to coordinate or speed those processes, so delays increase and patients spend longer in the beds. When there are few free beds, the system feels pressure to discharge more patients and they speed up, lowering the length of stay.

That this is a problem is reinforced by other strands of evidence. Clinical audits of all the patients currently occupying beds often suggest that a quarter to a half of them are fit to leave an acute hospital (but haven't been discharged yet for reasons unrelated to how fit they are). The delayed discharge stats–which assign primary responsibility for the delays to long stay discharges–usually pin more of the blame on hospitals than on social care organisations (despite the social care problems being talked about a lot more).

Adding more beds doesn't change the discharge process but reduces the incentives to get it right. Perhaps putting more effort into consistent disciplined discharges would yield a faster benefit than adding more beds (and also lay the foundation for extra future beds to provide a bigger benefit).

The way we measure bed occupancy is wrong

This brings us to another very serious problem: we measure the wrong thing in current metrics about bed occupancy. Arguably the current metrics for occupancy in the NHS are actively harmful to better bed management.

I've ranted about this problem before. In essence what the normal metric measures is how many beds are occupied at midnight on a single weekday. But this tells us nothing useful about whether beds are being used effectively not least because it tells us nothing about whether beds are available at the time of day when they are actually needed for admissions. On a typical day something like 15-20% of patients will be discharged. But, if those discharges happen late in the day the beds will not be free at the time of day when there is the highest demand for empty beds (which peaks around midday). What matters for the patient and the hospital is whether there is a free bed at the specific hour of the day when the bed is needed. Whether the bed is free at midnight is only vaguely related to whether it is free when it is required. And not being free at the right time leads to very long delays for admission and those delays dramatically increase mortality for patients (according to emerging evidence) never mind the increased clinical workload and stress for staff.

The single thing a hospital can do to get more free beds at the point where they are needed is to change the timing of discharges. Doing this makes no difference to any of the commonly reported metrics about beds (it doesn't affect midnight occupancy nor does it alter length of say). So the metrics everyone looks at completely fail to inform anyone about the most effective action they could take to get more free beds at the point of need and therefore better flow of patients through the hospital. If anything, the current metrics actively distract hospitals from the most effective actions they could take.

Of course most hospitals have some process to get a grip on where there free beds are. But those processes are rarely informed by good data on the live state of the beds. Imagine arriving at a hotel to occupy a room you booked weeks ago only to find the hotel has to send someone to walk the corridors to find out which rooms are free. That's not too far from how many hospitals manage their beds. Automated systems to record the live, hour by hour, bed occupancy are extremely rare despite the fact they would create vital data for doing a better job of managing the beds and support big improvements in discharge planning and patient flow.

We could probably get bigger and faster improvements if the central NHS bodies abandoned the current metric and, instead, insisted that every hospital should have reliable, real time occupancy statistics. At least then there would be evidence to drive better discharge timing and planning which could easily yield far bigger benefits for patients than most other initiatives.

85% occupancy is a stupid target that actively harms hospital strategy

The majority of stories on the latest bed crisis will quote the "safe" occupancy level for hospital beds of 85%. But this number is nonsense and focussing on it distracts from good bed management. It is a classic zombie statistic popular not because it is useful in any way but purely because it fits in a nice headline.

Few people read the original source of the number or understand the assumptions behind it. There are several problems with the number and its implications for what hospital policy should be.

A very detailed explanation for why the specific number is almost always the wrong target is given in this excellent paper by Simon Dodds. Part of his argument is that hospitals need to know for themselves what their target should be based on their characteristics (size, timing and volume of patient flow…). A focus on the 85% actively distracts local management from understanding their local circumstances and adopting the right policy to improve it.

Another reason for discounting the 85% is that the model that generated it deliberately ignored some of the most important factors that hospitals can control. Both admissions and discharge are assumed to be basically random which they are not. More importantly, the model completely ignores the issue of discharge and arrival timing so give a result that is true only if hospitals can do nothing about timing (hospitals could control the timing of elective admissions and the timing of all discharges and emergency admissions are fairly predictable).

We have a widely quoted target that encourages hospitals to ignore both their specific local circumstances and many of the most important actions that could improve their local flow of patients. A target that encourages hospitals to ignore what they do know and distracts them from what they could do about it is not a useful target.

What should hospitals be doing?

The campaign for more beds is bad for the NHS because it implicitly asks the wrong question. We should be asking "what actions can we take now to most improve the flow of patients though hospitals". There are plenty of answers to this question that could yield improvements far faster than any reasonable strategy to add more beds. And, even if we do need more beds, there are plenty of other actions that the NHS needs to undertake first before the extra beds will provide much benefit for patients.

Adding more beds is not a useful short term solution anyway as it is impossible to deliver without other parts of the NHS being improved (staff recruitment and retention for example). Staffing problems are, in turn, driven by the poor working environment in many hospitals. And this is partly a function of the poor coordination and management of staff, beds and patients and exacerbated by naive management bullying of staff to "work harder". Designing better ways to work would yield both a direct benefit in better patient flow and would also improve the working environment for staff making recruitment and retention better.

The fastest way for a hospital to get better flow is for it to achieve better coordination of the arrival and discharge processes (see this blog for some examples). Getting this right can dramatically increase the number of free beds at the times of day where free beds are needed (even though it doesn't affect the current metrics on occupancy or length of stay). Well-coordinated processes are also less stressful to staff and less wasteful of their time (too much of which is currently spent trying to find free beds or pushing for inappropriate discharges). This might also be the key to improving the retention and recruitment required to actually staff more beds in the future.

Achieving better coordination might require hospitals to invest in both technology to track patients and in the management expertise required to develop better processes for coordinated discharges and admissions.

Not only would a policy focus on better coordination be likely to yield actual improvements in flow relatively quickly, but it might be an essential prerequisite for any future drive to increase the number of staffed beds.

Campaigning for more beds isn't just naive, it actively stops us taking the right action to improve how the NHS manages its beds.

You can't make the NHS better by optimising its components.

In a system with many interdependent parts trying to optimise the parts separately doesn't optimise he whole. Local optimisation doesn't lead to system optimisation. This is a lesson NHS management needs to learn in many areas from how emergency care is managed to how the costs of diabetes are minimised.

There is an old (possibly apocryphal) story about the perils of central planning. Stalin issues a demand that factories improve their productivity by producing more output for the same number of hours worked. Some clever factory manager realises that the switch from producing left-footed shoes to right-footed shoes wastes time so he mandates that the factory only produces left handed shoes. Output of shoes rises significantly and he makes his productivity target. But, of course, this is terrible for the people as one left shoe is useless by itself (unless you are a one-legged war veteran who lost his right leg and there are few of those not least because war injuries don't discriminate which leg is blown off).

If your local metrics are wrong, factory productivity is not a good indicator of system productivity.

But this sort of naive focus on local metrics is, even now, a big problem in the NHS (which also suffers many of the other problems inherent to centrally planned systems).

The NHS is short of managers and is particularly short of skilled managers. The system sometimes seems to hate them not least because many politicians seem to regard them as parasites who suck resources away from the heroic front-line staff (even Sumproduct Phil's newfound largesse came with the warning that the extra cash should go to the frontline not the "bureaucrats"). But managers are necessary in any system not least because a poorly organised and coordinated system will function badly however many "front-line" staff it has.

One particular failing of management-lite systems is that there is nobody to do the system-level thinking that makes that coordination work. So, many management decisions are divided up into smaller decisions that can be made locally with no attempt to consider the system-level consequences. This is one factor leading to poor system productivity. The drive to improve system productivity is reduced to a set of local initiatives to drive up local productivity and, like the shoe factory, this doesn't achieve its intended goal.

Optimising A&E doesn't fix the A&E performance problem

Take, for example, the drive to improve A&E performance. It is all too common for this to be seen as a problem for the A&E department. So local managers devise local initiatives to improve staffing, reorganise flow, divert patients, develop clever ways of dodging the 4hr metric and so on. But these don't work. So leaders put more pressure on staff to work harder and do better. But the staff are demoralised from all the previous initiatives and become burnt out, increasing turnover and continuity. The initiatives repeatedly fail; morale and engagement fall. More pressure is exerted and the downward spiral continues.

I've ranted about why this happens plenty of times. But the key point here is that poor A&E performance isn't (mostly) an A&E problem. It is a system problem. Much of the problem is a failure of flow through beds (which are not controlled by the A&E department but by the specialites running wards). In turn, some of their problem is caused because the hospital is not in control of the systems in the community that can get patients the appropriate community care they need.

This problem needs joined up thinking to create any hope of a solution. Trying to fix it by putting more and more pressure on the A&E department is futile and, if anything, makes the overall problem worse.

Local optimisation doesn't lead to system optimisation.

Minimising the cost of blood-glucose testing doesn't minimise the cost of diabetes

In another example recently I heard of some CCG attempting to use RightCare metrics for the cost of diabetes blood-sugar tests to drive lower spending. Now there isn't anything wrong with trying to use the cheapest effective technology as this frees up money to use elsewhere for other treatments. All other things being equal, CCGs should aim to use the cheapest technology that does a good job. But all other things are not equal, and some of those other things matter a lot.

The problem here is that diabetes is a complicated area and what you do with testing affects the need for treatment elsewhere. The background is that diabetics with good blood sugar control have far fewer complications in the future. But it is also important to note that most diabetics do not test their blood-glucose often enough to achieve good control, partially because pricking your fingers 10 times a day in inconvenient and painful. We just don't prescribe enough blood-glucose test strips for all insulin using diabetics to test as often as they should. There is a reasonable case for saying CCGs should encourage more testing (or new technology like the Freestyle Libre continuous glucose monitor which, in effect, allows 24hr continuous testing for the same price as the recommended levels of finger prick tests).

But the easiest way to control the cost of glucose testing is the limit the number of test strips issued to that CCG's population. That is picking the wrong metric for the wrong local optimisation. Sure, if you limit the number of test strips issued you will look good on the spending metric compared to other CCGs. But your diabetics will do fewer tests, will have worse glucose control and will end up with more diabetes complications.

And this is really, really bad for the system as a whole. To see why look at the overall costs of diabetes. A recent estimate puts the cost of diabetes to the NHS at around £10bn/year. Drugs alone are only about 10% of this, costing a smidgen under £1bn in 2017 in England. Blood-glucose monitoring costs <£200m out of that total. Most of the rest (certainly 75% of it) is spent dealing with the complications of diabetes (in the long term many amputations, many cases of blindness for example, are caused by diabetes but, even in the short term, poor glucose control leads to many hospital admissions for high or low blood sugar which can be life threatening if not treated promptly).

So trying to limit the testing spend (the <£200m) might be good if considered in isolation. But it doesn't look so good if it involves any risk at all of increasing the multiple billions spent on complications. Which it does.

So far I don't know many CCGs trying to limit the spend this way. But most of them are guilty of making a similar sort of choice when it comes to new technology for testing blood glucose. Abbott's Freestyle Libre is a wearable monitor that tests blood glucose every few minutes to give a complete 24hr profile that provides the sort of insight that enables diabetics to achieve much better control. Libre would cost about £900/yr if CCGs made it widely available. This is about the same cost as conventional testing for diabetics who test 10 times/day (which is what they need to do to get good control as NICE advises). But most diabetics don't test that much so moving to Libre would cost more and CCGs are resisting that switch (and inventing incoherent clinical reasons to justify that stance). None of the CCG documents justifying this stance even mention the other costs of diabetes or how they could be improved by more blood-glucose testing leading to better control.

Their local optimisation of the cost of glucose testing is a catastrophe for the total cost of treating diabetes across the whole NHS. Even a modest improvement in average blood-glucose control would yield a huge gain in the cost of complications. This will never happen if all CCGs consider is the local cost of testing.

In a complex system like the NHS local optimisation is dumb

The point uniting these two, very different, examples is they both involve local optimisation and a failure to think how one part of the NHS is connected to other parts. Trying to fix the whole NHS by telling its parts to maximise their productivity or minimise their costs doesn't work.

Every part of the NHS needs to understand how it fits into the system and how it interacts with the other parts. And everyone's goal should be to make the system work better not just their little, local part of it. Productivity in the NHS won't improve if we don't

Asking the wrong question about GP behaviour is even worse than getting the wrong answer about it

A recent survey based on an NHS England idea suggested that 10-20% of GP appointments were avoidable. But the answer is useless as the wrong question was asked to the wrong people at the wrong point of the process. Worse, the very way the survey was framed was built on false assumptions about how GPs could work leaving the most important question unanswered: what would happen if GPs organised their work differently. It is astounding that such a bad survey was commissioned and has any influence over NHS policy.

That GPs are overloaded with demand and overworked appears to an almost unquestioned belief in the current NHS. So it should be important to understand what can be done about this. We need data. We need good analysis. We need better ideas about what to do.

So when I saw reports concluding that 20% of GP appointments were avoidable, I thought they might be the result of a careful analysis of what was going on.

But I was wary. Similar surveys of A&E attendances conclude that too many people go to A&E instead of other services. This observation is, however, useless as it fails to consider that these people are not the cause of poor A&E performance and we have no idea how to make the go anywhere else. Therefore useless for policy, unless wish fulfillment is now a major element of NHS planning.

Sadly, despite the amount of effort put into the GP survey by The Primary Care Foundation, the same is true of its results. In fact they might be worse.

As far as I can tell the key survey asked GPs at the end of a sample of appointments whether that appointment could have been avoidable. Nationally they thought that perhaps 20% could have been handled by someone else (by which they mean some mix of nurses, pharmacists or other staff). So far so good. The results might even be true.

But they have asked the wrong question to the wrong people at the wrong point in the process.

What if, instead of waiting for patients to get through the typically annoying process to get a 10 minute slot with their GP, they asked, instead, how many of the people granted an appointment actually needed an appointment to sort out their problem? By assuming that every patient interaction has to involve a 10 min appointment we have already made the strong assumption that 10 minute appointments are the only way GPs can respond to demand. And that demand can be mitigated–but only slightly–by using a different mix of staff in the practice combined with better signposting.

We have good evidence from a number of practices that changing the way GPs respond to demand can have a much bigger impact than this. Scores of practices have switched to different processes where the GP interacts with patients before booking appointments and only offers face to face appointments to those where the GP and patient agree it is required. These GPs typically find that 60-70% of demand can be handled without an appointment. In the practices that get this right the GP workload goes down substantially and patient satisfaction soars as they typically get fast on-demand responses to their problems and same-day appointments when they need them (rather than having to wait a week or two for the next available slot). See this tweet from GP Dave Triska, for example (he tweets his experience regularly and it is well worth checking out his feed).

The problem, these GPs have realised, is that the assumption that the only tool they have is a 10 minute appointment is false. There are plenty of other ways to respond to many patient requests and most of them are far more efficient that 10 minutes spent face to face. Sorting this out before spending 10 minutes in front of the patient saves a lot of time for both.

What the Primary Care Foundation should have done is to survey the incoming demand to GP practices and asked whether a face-to-face appointment was the best way to respond to that demand. By failing to do this they embedded the false assumption that 10 minute slots are the only tool in a GPs toolshed. This reinforces the false belief that there is no alternative and that the best we can do is to make minor adjustments inside the practice or, somehow, deflect the demand somewhere else.

The net result of this bad survey will be to blind GPs and policymakers to far better, more radical alternatives. That's really not the best way to get data telling us how to improve GP practice.

Knee-jerk ideology makes any sensible debate on the NHS virtually impossible

The NHS needs to improve. Most people agree with that. But when it comes to what specific policies or actions will deliver improvement there is far less agreement. So sensible debate about what to do would be useful. Sadly we are unlikely to ever have that debate when the response to any suggestion consists of a storm of ideological name calling.

A recent opinion piece on the BBC's Newsnight programme about the NHS has led to a storm of protest and abuse. The piece consisted of a short video by Kate Andrews of the IEA (a free market think tank whose funding is not very transparent). The response mostly consisted of arguments like this:

1. The BBC should not provide a vehicle for right wing propaganda
2. Kate Andrews doesn't understand the NHS because she is an American
3. The IEA is an evil propagandist for an insurance based system and NHS privatisation
4. The USA's health system is evil
5. The BBC is biased

And more on the same lines.

Before I watched the video I assumed that she must have argued that the NHS needed to be financed by user charges and broken up into an american style mess run by the private sector for profit. Then I watched it. And my reaction was "what the holy fuck are those commentators talking about?"

The key arguments in the video are this:

1. The NHS is in a state of perpetual crisis
2. There is little appetite for radical reform
3. Campaigners often pretend that there are only two alternatives: the NHS or the US "system"
4. The NHS isn't on reasonable metrics "the envy of the world": outcomes are better in many other health systems
5. The USA is a crap system but is also an extreme outlier and a meaningless comparison
6. Many other countries (Australia, Singapore, The Netherlands, Germany, Sweden…) have universal healthcare with better outcomes than the UK
7. Competition between a variety of providers (both profit and non-profit) is a common factor in other universal care systems
8. Market reform in the NHS would be good

And that is it. No calls for abolishing "free at the point of use". No calls for privatisation. No praise at all for the US system.

The only contentious call is for more market reform in the NHS. The most left-wing pro-NHS campaigners agree with point 1. Point 2 is arguable but not controversial (unless you think that abolishing the Lansley act is radical which it isn't as returning the NHS to previous legal and structural model is a big change, but a conservative one). Point 3 is simply a summary of what the majority of commentators and campaigners seem to argue. Point 4 is solidly based on facts. Point 5 is also uncontroversial (though the fact that someone from the IEA has just said it ought to be interesting and pro-NHS campaigners might like to quote it a few more times in their arguments). 6 is also true but, annoyingly, rarely mentioned in the debate about what we should do to improve the NHS. Also 7, which probably explains why left-wing campaigners rarely mention 6 as it undermines the simplistic idea that provider competition is the root cause of everything wrong with the NHS. 8 is admittedly contentious and worth arguing about, though not for the reasons campaigners would normally use.

On that last point it is worth a quick diversion to see what good arguments against it would look like. The best argument isn't that competition doesn't work: it does, even in the NHS as respected and non-ideological health economists like Carol Propper have shown. But those studies showed that the benefits to quality were, likely, small (though the NHS's experiments with competition for elective procedures were not very radical). More importantly, more competition would do little to address the immediate short-term problems in the NHS even if they improved quality in the long term. We have more important things we need to tackle right now like gross underfunding, especially of capital and improvement projects.

So I can take Kate Andrew's argument and deal with it like an adult, specifically looking at what she argues for and rebutting it with logic. A disturbing amount of comment, however, looks less like a fight in a primary school playground and more like a shit throwing contest between two opposing tribes of agitated chimpanzees (seriously, read the twitter thread on the Newsnight post).

It is hard to judge whether any of the shit-throwing commentators even watched the video. I thought more might have latched onto her criticism of the US model ("even the IEA think healthcare in the USA is rubbish!"). What we actually got as a typical response was a series of ad-hominem attacks on Andrews and the IEA coupled with damning criticism of BBC bias for daring to allow such dangerous views to be broadcast (despite them clearly being labelled as an opinion piece to provoke debate and comment). Yes, the opaque funding of the IEA should make us suspicious of what they say and forensic in examining the facts and arguments they make, but it doesn't automatically render what they say as mendacious nonsense.

Much of the comment validates a point I have made before: it is impossible to discuss the NHS in ways that might help improve it because the "debate" is is conducted in clichéd shibboleths where all that matters is proving which side you are on. Identifying real problems and fixing them is utterly irrelevant.

If we really want to fix the NHS (and spend the government's new found largesse well) we need to dispassionately analyse what the real problems are and apply the new money to solving them. We need to look objectively at the facts and not just ignore the ones that don't entirely match whichever ideological agenda we have. The intemperate shit-throwing of the pro-NHS commentariat does not exactly encourage that debate. And the likelihood of finding good ways to make the NHS better is substantially lower as a result.