NHS hospitals in England are “full to bursting”, says The Daily Telegraph, while The Guardian highlights concerns over “worryingly high” death rates in some hospitals.
The alarming headlines are based on an annual Dr Foster report on hospital statistics. The independent report looks at areas such as mortality rates, bed occupancy rates, staffing and efficiency, and access to treatment in each hospital.
The report says that most hospitals are under pressure from rising numbers of emergency admissions, particularly among frail and elderly patients. It also found wide variations in hospital mortality rates, with 12 trusts showing rates higher than would be expected on two out of four measures used to gauge death rates.
The report also raised concerns about NHS inefficiency, citing the fact that around one in three hospital bed-days are caused by patients whose ‘admission might have been avoided if their care was better managed’.
The report has been published by Dr Foster, an independent research organisation that produces guides to the quality of the health services in both the public and private sectors. The guides are based on individual hospital trusts’ performance data. For the past 11 years, Dr Foster has published analyses of hospital performance through its annual hospital guide. The 2012 Dr Foster guide ‘Fit for the Future?’ is available for free online (PDF, 664KB).
Dr Foster works with many NHS organisations to help them analyse the quality of patient care to make improvements.
Pressure on hospital beds
The report points out that the number of acute hospital beds has decreased by a third in the past 25 years as hospital stays have become shorter. However, it says admissions are rising, especially for groups such as the frail elderly. This is one of the main causes for growing pressures on hospital beds, which it highlights as including:
Trusts that provide cost effective care by reducing length of hospital stays, avoiding emergency readmissions and using resources effectively can also achieve good outcomes, says the report. At a time when budgets are under pressure, the report says efficient care must be delivered, but not at the expense of quality.
Areas of inefficiency include readmissions, unnecessary admissions, patients spending too long in hospital, wasted outpatient appointments and little elective surgery being carried out at weekends. For example, it says that one million hospital stays are unnecessary – of little or no benefit to the patient or the taxpayer, and that:
Fair access to treatment
The report points out that the level of treatment provided to patients declines as they get older and medical intervention is less appropriate. However, the degree to which this happens varies and may reflect lack of access to services for older people, rather than the views of patients themselves. For example, older women who have a mastectomy may have less chance of being offered breast reconstruction surgery. However, over-treatment of older patients can be as much of a problem as under-treatment.
Variations in levels of treatment suggest they may at times be driven by availability of resources and the views of clinicians rather than those of patients.
High mortality rates persist
The report says that wide variations in hospital mortality rates persist. The report uses four measures of mortality (see below) as a warning sign that poor quality care may be leading to a higher than expected mortality and that further investigation is needed.
Dr Foster uses four different types of measurements to assess an individual hospital’s mortality rates, which are:
The use of four separate measurements adds weight to the finding of the report’s analysis.
For example, a hospital may have a high rating in one measurement, such as deaths after surgery, for purely blameless reasons.
It could be the case that it performs a greater number of high-risk surgical interventions in severely ill patients, than most hospitals.
However, higher mortality rates than would be expected in two (or more) measurements would usually be seen as a cause for concern.
The report does not make formal recommendations, but it does highlight five main problems that need to be addressed by the NHS in order to improve both the effectiveness and efficiency of services.
Firstly, many of the people currently in hospital beds are there because of a lack of access to more appropriate treatment. Last year for example, nearly 55,000 people were admitted as emergencies with a diagnosis of “nothing more than dementia”. The report says that “hospitals are becoming refuges for those who have been let down by the wider health system”.
This then leads to the second problem highlighted by the report – bed occupancy rates, which in certain parts of the country and at certain times of the year, can be as high as 92%. Previous research has found that once bed occupancy rates rise above 85% it is more likely that problems affecting patient care will develop.
Thirdly, it says that there is patchy provision of care for elderly people, with some elderly people not being offered treatments (such as breast reconstruction surgery after a mastectomy) that would be offered to younger patients.
Fourthly, despite being a recognised problem for many years, the mortality rates during weekends are much higher than during the week. Hospital trusts need to do more to make sure that more senior medical staff work at the weekend.
Finally, there is a great deal more that hospitals can do to increase efficiency and savings without compromising patient care. They mention expensive MRI scanners going unused at weekends due to lack of staff, or hundreds of millions of pounds being spent on readmitting patients for problems that could have been avoided if recommended care protocols had been followed.
Dr Foster’s co-founder, Roger Taylor, says that much of what needs to be done to solve this rests with GPs, community services and social care. Nevertheless, he also says more could be done by hospitals to improve efficient use of resources by, for example: