Does the NHS need construction’s medicine?

Patients and surgeons are both being kept waiting by a shortage of beds. Building more facilities to house them is one obvious solution

It’s easy to sit comfortably watching telly shouting simple answers to the world’s most complex problems. We all do it. Well, some of us.

So, there’ll be plenty of viewers of the BBC’s Hospital documentary (apologies to those who haven’t seen it) puzzled and irritated. Why are surgeons and their highly-trained teams prepped and ready to operate but being stood down because of a lack of hospital beds?

This is not isolated to Imperial College Healthcare NHS Trust, which was featured in the documentary. Its statistics on bed availability suggest it’s far from the most stretched.

A recent blog by the president of The Royal College of Surgeons says: ‘Overnight bed occupancy rates are at the highest level for 16 years and all the RCS surgical specialties are now missing the 18-week target in England. Much of the attention has been given by the media to A&E but every part of the NHS is under pressure.’

What a waste. As viewers watch eager surgeons unable to operate and stoic patients having to discard their hospital gowns and return to their anxiety-riddled waiting list you can almost hear thousands barking, bemused: ‘Buy more beds.’ Or, from those more construction minded: ‘Build more bed space.’

Such suggestions seem more than reasonable. They are. But it’s never that straightforward. Not all beds are the same. Not all the problems of emptying beds lie within the control of the hospital staff. Increasingly, especially as the population ages, post-hospital social care has become the constraint.

The pressure can be seen clearly in the statistics. As well as having enough beds for patients, the NHS needs unoccupied beds to allow for cleaning, the randomness of patient demands and other contingencies. The recommended average occupancy for a hospital is 85%, according to the health information provider NHS choices.

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    Chart 1
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Chart 1 shows the average bed occupancy across NHS England. There will be a spread of performances above and below this measure. For most English hospitals the recommendations will be a retreating aspiration rather than reality, as occupancy levels are rising.

Despite all the complexities, few contest the simple assumption that something needs to be done.

One pertinent question might be: Is there a case for boosting spending on construction?

Before considering pumping money into building works, it’s worth examining how we got to where we are and why.

For years the trend has been away from the classic ‘Carry on Doctor’ cliché of rows upon rows of beds, filled with sick people sucking thermometers. Smarter, less-invasive operations mean people recover more quickly and fewer beds are needed. Medical advances also mean that operations, once rare, become routine. About 80,000 hip replacements, for example, are now carried out in England each year. This increase in procedures puts upward pressure on admissions.

The balance of evidence, however, suggested a need for far fewer beds. This has been reflected in a steep reduction in beds available in England from around 300,000 in the late 1980s to below 160,000 by 2010. Currently the number is about 130,000 across all disciplines.

But there are now fears this approach may have been overcooked given the demand the NHS faces today.

However smart our foresight might be, it’s never perfect. Often, far from it. Circumstances change, so projections of future trends must morph. What made good sense, say, 15 or so years ago – when planning for many of the facilities we rely on now was in full swing – doesn’t necessarily meet today’s needs. That should not be seen as a criticism of the original planning – but perhaps a failure of reassessment.

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Let’s consider one simple but critical factor in planning that is notoriously tricky to predict – population growth. What were the data telling us 15 years ago?

Here’s a snippet taken from the ONS’s Population Trends spring 2002: ‘The 2000-based national population projections, carried out by the Government Actuary at the request of the Registrars General, show the population of the United Kingdom rising from 59.8 million in 2000 to nearly 65 million by 2025. Longer-term projections suggest the population will peak at nearly 66 million around 2040 and then gradually start to fall.’

Clearly this hasn’t happened. The UK population topped 65 million in 2015 and there’s little sign of a peak. The latest projections (based on 2014 data) are for the population to increase 9.7 million over 25 years to 74.3 million in mid-2039.

The experts did an honest job, but population predictions are inherently unreliable. It wasn’t until around 2006 that the likelihood of the forthcoming rapid population rise became apparent.

Furthermore, it’s not just the size of the population that matters where health is concerned. Age distribution is important. Comparing population expectations made in 2002 with today’s reality shows there are more than a million extra children under 15 and about 150,000 more people aged over 60. These are age groups where we might expect higher demand on the NHS.

If we knew in 2006 of the impending greater stress from a larger and more demanding population, in an ideal world there would have been an appropriate surge in capital spending on the health infrastructure to match. Given that it would help.

Fiscally this is not unreasonable or irresponsible. An expanded population, particularly that resulting from net migration, creates greater economic capacity and the potential for greater tax revenue.

Obviously capital investment needs planning. So if the signal of rising population came in 2006 we might not expect a boost to capital spending to feed through much before, say, 2008 at the earliest.

Ah, there’s the rub. A recession. Austerity. And a consequent squeeze on funds for capital spending. The health sector was not immune. 

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Capital spending may not be all about construction, but the industry’s output figures are revealing. Chart 2 shows the massive surge in health related work between 2003 and 2009. At peak more than 7% of new construction work was in the health sector, double the previous spend.

The years since have seen a major decline, despite the rise in demand.

In reality, capital spending and moves to increase the number of beds is not the only cure, although it may be part of it. The post-recession squeeze on funding for social care has added to the pressure on beds. The watchdog, the National Audit Office, last year found sharp rises in delayed transfers due to the increased time spent waiting for home care packages. The number of days of delay rose from 89,000 in 2013 to 182,000 in 2015.

This all leads to the calls we hear for more joined up thinking.

However, if we look at the capital spending of the NHS over recent years we see clear evidence of persistent underspend of the capital budget amounting to more than £2 billion from 2010-11 to 2015-16 being used to cover running costs. The annual report 2015-16 states: ‘…the department looked at all areas of spending and took the opportunity to re-prioritise some spending to support frontline services.’

The expediency is understandable. A recent national survey of NHS leaders in 2015 commissioned by the NHS Confederation, a membership organisation, found 71% of respondents agreeing that financial pressures were the worst they have ever experienced.

The choice, however, is questionable. As the health-focussed think tank The King’s Fund points out: ‘… short-term fixes – particularly cutting capital spending – risk storing up problems for the future.’

Data specially compiled by Barbour ABI illustrates the decline in recent years. Both the total spending on construction work and the number of health-related projects have been in decline. This suggests that there will be a further fall in health-related construction.

Finding solutions to the NHS capacity problem is a complex matter. Construction does not and cannot provide all the answers. However, construction is regarded, with good reason, as effective in raising productivity. In the health system, providing the bed-space for more beds should help, for instance, to release constraints on the productivity of some of our most valuable surgeons.

Certainly there appears, if only on the basis of a higher than expected population, to be a strong case for more construction and a harder look at how to find money to build more capacity.

This need not be simply be about constructing more space in hospitals, but, perhaps, building more suitable accommodation for those who should, but can’t safely, be transferred from hospitals.

As is made very plain in the BBC’s Hospital documentary, the challenges are not just about having the highly-trained surgeons and their highly-trained teams, it’s about providing them with the facilities to get on with their jobs unhindered by frustrations over capacity.