Inadequate acute hospital beds and the limits of primary care and prevention
- Paul Cunningham, FACEM, Staff Specialist; Jeremy Sammut, PhD, Research Fellow.
Correspondence: Dr Paul Cunningham, Emergency Department, Ryde Hospital, Denistone Road, Eastwood, NSW 2122, Australia. Email: firstname.lastname@example.org
Metropolitan Australia is suffering from a serious shortage of acute hospital beds. Simplistic comparisons with the Organisation for Economic Co-operation and Development bed numbers are misleading because of the hybrid Australian public/private hospital system. The unavailability of most private beds for acute emergency cases and urban/rural bed imbalances have not been adequately considered. There is a lack of advocacy for acute bed availability. This attitude permeates government, health professions and the health bureaucracy. Planners, politicians, analysts and the media have adopted false hopes of reducing acute demand by prevention and primary care strategies, vital as these services are to a balanced healthcare system. This paper directly challenges the ideology that says Australia depends too heavily on hospital-based healthcare. Rebuilding the bed base requires recognition of the need for an adequate acute hospital service and strong advocacy for bed-based care in the medical and nursing professionals who should be driving policy. The forces opposing bed-based care are strong and solutions might include legislative definition of bed numbers and availability.
Despite official denials, multiple credible Australian and overseas studies show the single-most important cause of ED overcrowding is shortage of acute hospital beds.[2-13] All point to the same solution. Hospitals need an adequate supply of staffed and supported acute beds per 1000 head of population.
The reluctance to accept and deal with the bed shortage has become a failing of our health culture. The cause is not because of lack of funds or strong counter arguments. There is simply an imbalance in the argument – advocacy for linking bed numbers to population is a minority view.
In response to media attention and mounting public concern about the state of public hospitals, poorly advised state and federal governments champion superficially plausible but erroneous non-solutions. In health we are through the looking glass and have reached the point that copious empirical evidence of the causes and consequences of hospital overcrowding, including excessive mortality rates,[14-16] is having little impact on policy priorities and outcomes.
Bed numbers in Australia
Health bureaucrats and planners commonly claim Australia has an adequate and ‘internationally comparable’ number of hospital beds. Official bed numbers appear to show that Australia has an equivalent number of beds – 3.9 beds per 1000 population – compared with the Organisation for Economic Co-operation and Development (OECD) average of four beds per 1000 population. This simplistic comparison is hardly reassuring. It presumes that the OECD average is the level of efficient function rather than the lowest point politically tolerable. It is comparing diverse health systems in which acute bed definitions are variable. It also ignores the fact that other countries close to the OECD average, such as Canada, have documented endemic overcrowding. Crude international comparisons of hospital admissions per 1000 population ignore unmet demand, which is the crucial issue. The argument that increasing bed supply is pointless as increased supply induces demand is perverse in this context. Nevertheless, the erroneous idea that long waits for elective and emergency treatment are caused by Australians overusing hospitals is driving policy.
The uneven distribution of beds across major cities and regional areas underestimates the uncommonly low number of acute beds in metropolitan Australia by international standards (see Table 1). It is sobering to note a UK bed average of 3.7 per thousand compared with Australia's metropolitan public bed average of about 2.6.
Table 1. Breakdown of national average of public hospital beds per 1000 population† by region
| || |
|Total all regions||2.7|
In the last 25 years, the total number of acute public hospital beds in Australia has been cut by one-third from 74 000 beds in 1983 to 56 900 beds in 2009–2010. Adjusted for population growth, there has been a 60% fall from 4.8 public acute beds per 1000 population in 1983 to 2.5 per 1000 population (2.6 per 1000 including psychiatric beds). This includes an 18% decrease between 1995–1996 and 2005–2006. Excessive bed closures mean public hospitals with significant emergency demand are unable to operate with sufficient spare bed capacity. True average occupancy in many major urban public hospitals is 90–95% and therefore peak demand commonly pushes occupancy over 100%.
Private hospitals contribute 1.3 beds – 33% of the national total. The majority of patients who present at public hospital EDs cannot be admitted to private beds because they lack insurance or they have the wrong diagnosis. Most Australian private hospitals, with a few notable exceptions, are not equipped to deal with the full range of emergency cases. Approximately 10% of all admissions identified as emergency admissions occur in private hospitals. Private hospitals could only be considered to be reducing demand in public hospitals if private admissions were clinically equivalent to the public sector. This is clearly not the case. Private hospital beds therefore do not make up for the shortage of public acute beds.
Evidence-based policy or procedural cherry picking?
Opening more beds is claimed to be unaffordable, especially in the context of alleged underfunding of public hospitals. This is despite recurrent expenditure on public hospitals increasing by 63% in real terms (adjusted for inflation) over the last decade.
Bed cuts commenced in the mid-1980s in response to procedural innovations. Falling lengths of stay – from an average stay of 7 days in the mid-1980s to fewer than four by the end of the 1990s – enabled hospitals to treat more patients, especially procedural patients, with fewer beds.
However, now a substantial proportion of the growth in day surgery is generated by technology stimulating new demand for new elective procedures rather than replacing and reducing multi-day stay demand.[30, 31]
Hospitals with a higher proportion of procedural and same-day patients benefit more from rising day surgery and from casemix funding systems. According to the June 2009 State of Public Hospital report, 67% of patients admitted to public hospitals receive acute medical care compared with just 18% requiring surgery. Since 2002, medical Diagnosis Related Groups (DRGs) have been growing at double the rate of surgical DRGs in public hospitals. Overnight and multi-day separations (which fell only slightly in the late 1990s) have increased by 12% since 2002, and average length of stay with same-day separations excluded (6.2 days) has remained relatively stable over the last decade, falling by less than 5%. If bed numbers were less important and if cuts to hospital bed numbers were an efficiency dividend reflecting surplus capacity and reduced need and usage, then there should be no hospital overcrowding. Despite this empirical reality, the conventional but outdated planning assumption is that bed numbers as ‘less important’.[26, 33]
Failure of bed advocacy among health workers and planners
Numerically small provider groups, including geriatricians, general physicians, hospital-based psychiatrists and ED doctors and nurses, face a constant shortage of a basic tool of trade. Despite limited support from clinical colleagues sympathetic to the plight of non-procedural specialists, the interests of other health professionals, for whom bed-based medical care is no longer a primary concern, have won out in the scramble for finite resources among a myriad of competing interests. Special pleading and ‘capture’ of the policy-making process at both the bureaucratic and political level means there is little institutional or political will within the public health system to rebuild the bed base despite the impact on patient care.
The advocacy imbalance, including the unceasing political pressure to cut elective waiting lists, has encouraged state health services to cannibalise bed numbers to direct resources to short-stay proceduralism and forays into community care. An example of this in New South Wales (NSW) was the Carr/Refshauge promise to halve elective waiting lists in the lead up to the 1996 state election. Procedural medicine is obviously a critical part of the system and many proceduralists and their patients have been negatively affected by bed shortages, but political emphasis on elective waiting lists has been at the expense of acute services.
Another cause of advocacy imbalance is the shortage of nurses (prepared to work shift-work on hospital wards), which further limits the capacity of already unwilling budget-constrained administrators to open more beds. Rather than address this, the health bureaucracy finds it easier to seek reasons why the beds are not required. Yet, the nurse ‘shortage’ is in reality a by-product of the withdrawal of trainee nurses from hospitals following the abandonment of traditional vocational nurse training in the 1980s. The leadership of the Australian Nursing Federation's is strongly opposed to the ‘simplistic option of opening more beds’ in favour of creating more community-based positions for nurses including autonomous clinical roles. As of June 2009, just 541 nurses had taken up the federal government offer of $6000 cash bonuses to return to the wards – half the number expected in 2008–2009 and a mere 7% of the 5-year target for the scheme. Low take-up led to the scrapping of the Bringing Nurses Back into the Workforce programme in early 2010.
It is time to ask why the changes to nursing training in the last 20 years have led to decreased numbers of graduate nurses committed to ward-based careers. The myth that the main problem in the nursing workforce is the retention of experienced nurses should mean the average nursing age is decreasing. In fact it is substantially increasing. This in part is due to increased average age at training commencement, leading to a shorter working life for nurses even if there is not premature retirement. However, the major problem is initial recruitment, training, production and retention of qualified nurses.[37, 38] From the consumer's point of view, the UK Patients Association believes that since the shift from bedside to university training, ‘nurses look to the personal prizes of nurse specialism and have been allowed to ignore the needs of their sick, vulnerable and often elderly patients.’
Primary and community care ‘alternatives’
The most vocal and active health lobby groups – especially the community health sector, with the prominent support of public health academia – have pursued their own self interests under the rubric of solving the hospital crisis. These groups have been remarkably successful in promoting their preferred policy agenda and in convincing politicians that (i) greater public spending on prevention, (ii) boosting the provision of primary care services, and (iii) the delivery of non-hospital ‘centric’ community-based chronic disease care, will reduce demand for emergency admission to hospital. Lobbyists advocate ‘investments’ in public health (an increase in spending on prevention to 10% of total health spending) and throwing more resources at so-called reforms (the National Preventive Health Agency), which will not address the root of the problems in hospital.[40-42]
Quality primary care is a crucial part of Australia's health system, but its role in hospital avoidance, although real, has been exaggerated. Federal health ministers are continuously badly advised on this issue.[43, 44] According to former federal health minister, Nicola Roxon, Australasian Triage Scale (ATS) 4 and 5 patients are a ‘proxy of primary care patients’. According to her successor as health minister, Tanya Plibersek, ‘hundreds of thousands of Australians every year are forced to attend hospital emergency departments after hours for health concerns that could be treated by a local GP.’ Yet, the admission rate for ATS 4 is approximately 20%, compared with 0.5% of community-based general practitioner (GP) encounters. ATS 4 and 5 patients are commonly referred to hospital by a GP and those who are admitted comprise a substantial amount of inpatient deaths.
It is also claimed that elderly so-called chronic disease patients could be kept out of hospital. Those suffering complex illness who are classified ATS 4 and ATS 5 could be seen and have their conditions better managed in primary care settings to prevent the onset of acute illness and the need for hospitalisation. Yet, this claim is based on a 2007 study of the drivers of emergency demand in NSW, which relied on anecdotal evidence.
The policy implication is that opening more beds is an ‘inappropriate investment’. Investing in alternative models of community-based care – hospitals at home and coordinated care schemes – can substitute for beds. The final report of the National Health and Hospital Reform Commission (hereafter the Bennett report) selectively used the evidence by citing the promising results of one chronic disease programme in Victoria that appears to have reduced hospital usage by participants. On this slender evidentiary basis rests the grand claim that large numbers of hospital patients can be more appropriately treated out of hospital. According to the Bennett report:
Almost 10 per cent of hospital stays are potentially preventable if timely and adequate non-hospital health care had been provided to patients with chronic conditions.
This statistic is drawn from the work of the Australian Institute of Health and Welfare and is unreliable as it is based on a simple list of ICD diagnostic codes without case analysis. For example, it presumes that a urinary tract infection is a minor condition whether the patient is well or with substantial comorbidities and whether they are 22 or 82.
The assumption that alternative primary care can reduce demand for admission is not empirically based. A discussion paper by Leonie Segal prepared to inform the Bennett report found that ‘the evidence here is equivocal’:
Some success in small scale intervention trials is observed, but this is not necessarily translated into larger population based interventions. While reasons can be posited as to why the ‘expected reduction’ in hospital admission did not occur, it is plausible that high quality primary care may be additive to, rather than a replacement for hospital care.
Schemes designed as substitutes in practice have complemented rather than replaced hospital care and thus increased hospital activity.[54-56] The main effect of coordinated care might be to uncover unmet need. Bringing forward demand for hospital services is no bad thing and hardly an argument against coordinated care. However, it does mean that coordinated care might well add to the pressure on hospitals. In New Zealand, for example, one coordinated care programme led to a 40% rise in hospital admissions, an outcome attributed to better monitoring of chronically ill patients' conditions.
The evidence that coordinated care can reduce use of hospitals by elderly patients is ‘weak at best’ both internationally and in Australia.[61-64] The Australian Coordinated Care Trial conducted in the northern suburbs of Melbourne targeted the key demographic – chronically ill patients aged 75 and over. Coordinating the care of a trial group of patients appears to have produced no significant reduction in hospital use compared with a control group who continued to receive their usual level of care from their GP.
Finally, it must be acknowledged that the vast majority of admissions of elderly patients with acute medical conditions lead to beneficial treatment and discharge to the patient's usual place of residence.
Limits of prevention
Healthier lifestyles and medical advances have resulted in significant falls in rates of heart attacks, strokes and death from cancer in certain age groups. The first effect of better prevention is that Australia already has achieved the second highest average life expectancy in the world. The second effect is people who once would have entered hospitals and possibly died while in their 50s and 60s have had their demand for hospital care not prevented but deferred and potentially increased.
Some analysts have claimed hospital bed numbers are less important and that the demand for hospital beds has decreased because the elderly population is healthier. The veracity of these claims relies on a selective interpretation of hospital usage statistics.
In the 1990s, demand for hospital beds remained static in the over-65 demographic. Bed usage by healthier people aged 65–74 fell by 6%. The proportion of bed days in this age group declined from 18% to 16%. However, between 1993 and 2001, the population aged over 75 increased by 36%. Hospital separations in this demographic increased by 89%. Growth in separations in the 75-plus age group accounted for the entire growth in separation of people aged over 65, with multi-day separations increasing by 42%. These figures strongly suggest demand for hospital care from people aged over 65 has been delayed or deferred for 10 years or so until people reach 75 and beyond. It is arguable that use of hospitals was reduced temporarily by a one-off disease prevention effect due, for example, to a major reduction in vascular disease. Such ‘one-off’ improvements must be maintained but will lose their impact as those saved from earlier death succumb to complex chronic disease with acute episodes and become repeat users of acute public hospital beds. The elderly are entering high dependency residential aged care facilities later than previously and are entering these facilities sicker than in the past.[48, 71]
This deferred illness and delayed demand for hospital care started appearing in public hospitals in the late 1990s, contributing to the emergence of serious overcrowding as increasing numbers of ‘frequent flying’, frail elderly patients with chronic conditions in association with other comorbidities and multi-system failures required care in EDs and unplanned admission to inpatient beds.
Between 1998–1999 and 2007, public hospital admissions increased faster than population growth by nearly 16%, and there has been a ‘strong upward trend nationally since 2000–01’. The rise in admissions is ‘mainly accounted for by an increase in acute medical care admissions’, which increased by 23% since 1998, and by 7% alone since 2004–2005.[24, 25, 28] The policy point is that endlessly trying to contain rather than meet the need for hospital care generated by elderly patients is a futile strategy. It simply is not possible to endlessly prevent the need for elderly patients to be admitted to hospitals.
The search for solutions has led to national investment in the 4-h rule, which State governments have agreed to mandate in compliance with the federal health agreement. The initial target of 70% of patients to be admitted within 4 h will be gamed and obscure the problem at best. The 30% of patients who will wait longer are likely to wait much longer in blocked EDs. Performance statistics that purport to show hospitals are meeting the target will not capture the reality of continued overcrowding.
This latest deflection from the core issue of bed numbers demonstrates that in the policy argument between the proponents of reducing the bed/population ratio and maintenance or increase of bed numbers, reduction continues to win. Non-solutions, such as diverting ‘primary care patients’ from EDs to GP Super Clinics, have also been oversold by health lobbyists to inexperienced politicians. Primary Care ‘Polyclinics’ have been tried in the UK with minimal effect on emergency attendance as predicted by the British College of Emergency Medicine.
A comprehensive solution requires facing reality and dispensing with the myths, medical politics, and wishful policy thinking surrounding the hospital crisis. There is a vital need for all stakeholders to accept the importance but ultimate limitations of prevention and primary care in limiting bed demand. They must recognise the role of hospitals in meeting the future health needs of the community and must therefore understand and support the need to rebuild the acute bed base.
Yet, it seems no number of inquiries, analyses, fora, recommendations and sad stories will lead to an adequate provision of beds in metropolitan Australia. As the Garling Special Commission of Inquiry recommended in NSW, further special bed occupancy research might help, but he also advised to maintain the existing ratio of beds to population for the moment. This would require an annual increase of 380 beds per year in NSW by 2016 – just to stand still (at p. 1004).
There is therefore a vital need to restore advocacy and professional support for bed-based care, especially within the medical and nursing professions. Political will, extending beyond the electoral cycle, is also paramount. Acute hospital beds when an individual genuinely requires one is an essential service. Therefore, specific legislation to mandate adequate population-based bed numbers and availability might be the only effective solution.