Acute Services Review (Hansard, 11 July 1996)

§ Lord James Douglas-Hamilton

The review is now complete and my right hon. Friend and I have considered the internal report which was prepared by the management executive following consultation with clinicians and others in the NHS in Scotland. The formal terms of reference of the review were to review the planning assumptions used by the NHS in Scotland in developing acute hospital services by considering:

(i). trends (in activity and changing patterns of care, resource utilisation, staffing etc);
(ii). factors which may affect those trends and the response to them (including the need to take account of peaks in demand); and
(iii). models which may be appropriate for acute services in future.

A copy of the report's summary of findings has been placed in the Library of the House. The main findings include:

Between 1979–80 and 1994–95 the number of in-patient and day cases has increased on average by 3.1 per cent. a year. For most of this period, up to 1991–92, the annual rate of increase was 2.5 per cent., but since then has risen to 5.5 per cent. a year.

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The rapid growth in the number of day cases explains much of the recent increase, and the proportion of elective patients treated as day cases has risen from 38.1 per cent. in 1991–92 to 52.2 per cent. in 1994–95.

The number of emergency in-patient admissions increased by almost 4 per cent. a year on average between 1991–92 and 1994–95, while the number of elective in-patient cases remained largely unchanged. Emergency cases as a proportion of all in-patient cases has expanded steadily and now account for 60 per cent. of all in-patient admissions. This means that the scope for accommodating peaks of demand in beds normally used for non-emergency work has diminished, and when peaks in emergency workload occur the disruption to the non-emergency work of the hospital is correspondingly greater.

The reasons for the growth in the number of emergency admissions is not well understood; a multiplicity of factors is involved. Aging of the population is not the principal reason and increases in admission are observed across most diagnostic categories. A significant part of the growth is explained by a relatively small number of patients who have numerous admissions within a five-year period. These are not readmissions due to treatment failure or to early discharge; the patients concerned are commonly over 75 and have appropriate need for admission arising from their chronic and multiple morbidity.

Emergency admissions show a predictable seasonal fluctuation, with peaks in the winter months. The size of the seasonal variation has remained relatively stable; between 1982 and 1994 the difference between the peak average occupancy and its low point averages 12 per cent. of occupied beds. The timing of the winter peak is most likely to be determined by cold weather and fluctuations in respiratory disease. During peak admission periods, length of hospital stay tends to increase despite the pressure on hospitals which, other things being equal, might be expected to reduce lengths of stay. This is because during winter peaks the increase in admissions is age related.

During the winter crisis of early 1996, Scottish hospitals managed to cope with difficult circumstances because staff worked flexibly and beyond their contracts. The situation in Edinburgh royal infirmary was exceptional in part because of failure of water supply, ward closures due to multi-resistant staphylococcus aureus, MRSA, infections and the increased number of accidents among the tens of thousands of Hogmanay revellers. The problems faced by hospitals were compounded by staff sickness. Many hospitals had contingency plans which worked well. Nevertheless, it is clear that staff were under considerable strain during this period.

There is a need to plan the management response to sudden rises in demand in terms of the overall "system of care". Health boards have a central role in ensuring the adequacy of plans and, through their service contracts, for ensuring that the needs of acutely ill emergency patients receive the appropriate priority in their requirements of providers.

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The emphasis given to "beds" and "occupancy" as measures of resource and efficiency fails to acknowledge the importance of case mix, staffing levels, and patient throughput per bed as determinants of workload intensity.

The suggestion that there should be a moratorium on bed reductions is unrealistic. Health services must change in response to new patterns of need, and in response to developing medical technologies. It would have implications for existing NHS and NHS private finance initiative schemes. Fixing for some indeterminate period of time one aspect of supply ignores the interplay between these changes, and could prevent the appropriate transfer of resources within hospitals and between hospitals and alternative forms of provision. On the other hand, the legitimate pursuit of greater efficiency and changes to accommodate changes in working practices need to be managed with proper regard to the quality of care, and the workload intensity which higher rates of throughput bring to hospital staff. Occupancy of hospital beds is only a partial measure of efficiency of these factors, and ought to be supplemented by other local measures of workload intensity in determining the scope for changes in bed complements.

The findings of the report and the way forward will now be discussed further with those who contributed to the review.

As a first step, guidance will now be prepared in consultation with the NHS. This will incorporate examples of good practice and will be issued to the NHS in Scotland later this year.

I will also ask health boards and NHS trusts to look again at their plans for peaks of emergency admissions in the light of the review's findings in order to satisfy themselves that these will enable boards and trusts to respond appropriately and effectively.

For the longer term, I wish to establish a much wider-ranging review of acute hospital services in Scotland. I will be seeking the views of senior clinicians and others on the scope, remit and timing of such a review in the coming months.