Select Committee on Public Accounts First Report


The Committee of Public Accounts has agreed to the following Report:—



1. In 1998-99 a record number of people - around 5.8 million - were admitted to hospital in England for at least one night. This was achieved despite a fall in the number of general and acute hospital beds in recent years, made possible by changes in patient care. Around 1.8 million people were admitted as elective patients, following referral by their general practitioner and a decision to admit by a hospital consultant. Nearly four million people were admitted as emergency patients, perhaps following an accident or sudden illness. In response to these growing demands on their resources, NHS acute trusts have been developing new ways of managing their in-patient admissions, beds and patient discharge.[1]

2. On the basis of a report by the Comptroller and Auditor General,[2] the Committee examined how:

  • Patient admission and bed management might be improved;

  • To develop better collaboration between NHS agencies and social services departments in the discharge of patients from hospital.

3. We drew two overall conclusions:

  • In managing the record number of people admitted to hospitals in England the NHS has had to balance emergency and elective admissions, and make difficult choices on a day to day basis. There is much good practice in the NHS in improving patient services, streamlining patient admission, reducing unnecessary cancellations, and managing resources, especially beds, effectively. But in 1998-99, 56,000 patients had their operations cancelled by their hospitals at the last minute for non-medical reasons, the highest since the Patient's Charter Standard on cancellations was introduced. At the same time, over 2 million bed days are lost each year because of delays in discharging people who are fit to leave hospital. The NHS Executive are spreading good practice through targeted funding and the government aim to reduce delays in discharge by 30 per cent by 2003.

  • The total number of hospital inpatient beds has been falling for many years. Between 1986 and 1997-98, the number of acute and general beds fell from 200,000 to 138,000. In part these reductions have reflected changes in medical practice, such as the growth in day case surgery and shifts in the way care is provided, for example a growth in community beds. The biggest fall has been in general beds, essentially for older people. In spite of a compensating increase in the nursing home sector, two thirds of beds are occupied by people over 65. A key factor in delayed discharge of these patients is delay in assessing their ongoing care needs and difficulties in finding them places in community facilities. The cost to the NHS of continuing to accommodate these patients is around £1 million each day. The provision and pattern of long term care and social services for older people has become a key issue for the government to tackle as part of their wider plans for the NHS.

4. Our more specific conclusions and recommendations are as follows:
On improving patient admission and bed management
(i)NHS trusts record the number of operations that are cancelled on the day of admission and the numbers of patients that do not turn up for their appointments. But most trusts do not know the extent of other cancellations that occur either before the day of admission or because the patient's medical condition does not allow the operation to go ahead. NHS trusts should improve their recording and understanding of cancellations to help them improve their working practices (paragraph 34).
(ii)Hospitals could make better use of their resources, including beds, by reducing unnecessary cancellations for medical reasons or because patients do not turn up. Good practice, such as the use of pre-admission assessments, admitting patients on the day of their treatment, and improved booking systems need to be implemented more widely. The National Booked Admission Programme provides a good way of helping to drive through change (paragraph 35).
(iii)The total number of hospital inpatient beds has been falling for many years. In 1986 there were nearly 200,000 acute and general beds. This had fallen to 147,000 in 1993-94 and then to 138,000 by 1997-98. There is a clear relationship between high bed occupancy and the risk of cancelling elective admissions. This risk becomes very pronounced at occupancy levels above 83 per cent. Bed occupancy rates in hospitals ranged from around 50 per cent to 99 per cent in 1997-98. The average across all hospitals was 81 per cent (paragraph 36).
(iv)Changes in clinical practice over the years have enabled hospitals to treat more patients with fewer beds. But we are concerned that some hospitals are now operating at very high levels of bed occupancy of up to 99 per cent. The combined effects of year on year efficiency gains may have restricted hospitals' ability to cope with the increasing demand. We note that additional funding is now being made available to help provide a more responsive service (paragraph 37).
(v)The biggest fall has been in general beds - essentially for older people, though there has been a compensating increase in the nursing home sector in the period. While people over 65 represent 16 per cent of the population and 36 per cent of hospital admissions, they occupy about two thirds of beds. The provision and pattern of services for older people is the key issue. Additional funding and facilities have been announced in the Budget and in the NHS Plan of July 2000.We look forward to the introduction of more detailed guidelines for assessing future bed requirements and the balance to be achieved between different types of services at local level (paragraph 38).
(vi)Good information systems that provide real time information on current and planned use of key resources are essential in helping bed managers and other hospital staff to plan patient admissions effectively. Some trusts have succeeded in developing good systems, for example at Shrewsbury. However, in many trusts systems are inadequate and adapting existing systems can be complex. The NHS Executive plan to incorporate inpatient planning and bed management within their wider strategy for developing network systems and the electronic patient record. Our concern is that until these systems are available, many trusts will continue to operate for the foreseeable future without the information they need (paragraph 39).
(vii)We are therefore disappointed that the NHS Executive have not done more to build on the success of the system developed in Shrewsbury. The NHS has a record of slow and patchy progress in implementing IT projects, as we have seen in our previous hearings most recently on the Hospital Information Support Systems Initiative (HC 97 of Session 1996-97) and the 1992 Information Management and Technology Strategy (HC 406 of Session 1999-2000). When successful systems are developed, with real demonstrable benefits to patients, the Executive need to invest in implementing them more widely, rather than leaving NHS Trusts to re-invent the wheel. In taking forward the new NHS IT Strategy, the NHS Executive therefore need to work with NHS trusts to ensure they have a clear understanding of the likely timing and impact of the new systems, and of the costs and benefits of implementing interim solutions in the short term (paragraph 40).
(viii)The Comptroller and Auditor General's report demonstrates clearly the scope for more NHS trusts to introduce and build on the range of good practice in bed management and managing patient admissions. The NHS Executive have a key role to play in disseminating and encouraging good practice, and they have launched a number of initiatives. They are also looking at how additional funding can best be directed to support and incentivise the wider application of good practices. The success of these new arrangements will depend on getting the right balance of guidance, instruction and incentives to ensure that hospitals and other agencies introduce the changes needed. The NHS Executive need to track progress closely, evaluate the impact of these measures, and take remedial action where progress is slow (paragraph 41).
On the need to secure better collaboration between NHS agencies and social services departments in discharging patients from hospital
(ix)Over 2 million bed days are lost each year because of delays in discharging people who are fit to leave hospital. The key internal factors in these delays are poor co-ordination within hospitals arising from the timing of decisions to discharge and delays in the provision of transport and pharmacy services. The NHS Executive are working closely with hospitals to bring about the necessary changes to their internal systems and traditional patterns of working to enable patients to leave hospital promptly once they are fit to do so (paragraph 49).
(x)Many delays in discharging patients arise because of delays in assessing the ongoing care needs of older patients and difficulties in finding them places in community facilities that are most appropriate to their needs. The cost to the NHS of continuing to accommodate these patients, at around £1 million a day, is money that could be better spent on the treatment and care of new patients (paragraph 50).
(xi)Providing good quality services to patients depends crucially on a strong partnership between hospitals, general practitioners and social services departments. Health authorities have a pivotal role in sponsoring close collaboration between the parties involved, and in bringing forward practical solutions to overcome the administrative barriers to joined-up working. We therefore welcome the injection of £365 million to encourage the provision of more cost-effective community facilities and models of care. Targets have been set to achieve a 30 per cent reduction in the number of delays by 2003 and further measures have now been proposed to achieve timely discharge of patients and closer integration of health and social services (paragraph 51).
(xii)Discharge co-ordinators are effective in building bridges between all care providers to achieve appropriate and prompt patient discharge from hospital. Seventy per cent of NHS trusts now have discharge co-ordinators and we look to the NHS Executive and Health Authorities to spread this good practice to the remaining 30 per cent of trusts (paragraph 52).

1  C&AG's Report (HC 254, Session 1999-2000) paras 1, 3-8 Back

2  ibid Back

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2001
Prepared 25 January 2001