Hospital bed utilisation in the NHS and Kaiser Permanente

Editor—The comparison by Ham et al of bed utilisation in the NHS and Kaiser Permanente indicates that the NHS could improve its management of beds drastically but leaves open the possibility that it could be expensive in effort and money to reach the degree of efficiency at Kaiser.¹ However, a body of direct evidence from other statistics in the NHS already shows that large improvements are possible and likely to be cheap to implement.

Length of stay varies greatly in different hospitals (and for reasons not readily explained by demographics or differences in specialisations). In most hospitals the expected length of stay varies by around one day, depending on which day you arrive (a pattern with no conceivable clinical justification).²

Our models build a picture of hourly bed utilisation given known patterns of emergency arrivals (which are random), elective arrivals (which are, at least in principle, subject to management control), and discharges (which are definitely under management control). They show that the observed variations are largely due to the widespread practice of not discharging many patients at weekends. For a hospital with a length of stay of about seven days (about average), the consequence of not discharging patients at weekends is to waste at least 30% of the effective bed capacity.

Figure 1.

Data nearly two years on

Our evidence shows that few hospitals try to manage discharges and planned arrivals: in many trusts elective “planned” arrivals are more variable than (and uncoordinated with) emergency arrivals. Discharge during weekends requires consultants either to run discharge rounds or to set criteria for nurseled discharges. Neither of these options is an expensive change.

We know how to improve bed management in the NHS, and it is not expensive. The biggest barrier is not a lack of resources but a deep rooted unwillingness to change working practices for the benefit of patients.