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RECENT coverage of the pressures, compounded by the COVID-19 pandemic and health care workforce shortages, on public hospitals and acute care delivery across Australia has emphasised how vulnerable the Australian acute care system really is (here, here).
As hospitals represent the face of the modern health care system, and cost the most in terms of health care spending, their problems get emphasised more than other parts of the health care system (here, here). In such times, when hospital overcrowding and pressures on the clinical staff come under significant scrutiny, an often-repeated demand from various stakeholders to deal with these issues is for more hospital beds (here, here, here).
Governments, in response, make announcements of the allocation of more beds or even new hospitals (here, here, here). However, are more hospital beds and hospitals the solution to the acute care crisis? Would the provision of more hospital beds lead to sustainable solutions and align the Australian health care system to the 21st century practice of medicine?
Perhaps not.
Hospitals and hospital beds
In Australia, hospitals are a critical component of the health care system and are the foundation for the acute care system. Hospitals deliver both admitted and non-admitted services through both public and private hospitals. Even though public hospitals are owned and managed by state and territory governments, with partial funding from the Australian Government, private hospitals are owned and managed by private organisations and subsidised by the private health insurance model.
In 2020–21, there were 697 public hospitals in Australia, and as per the most recent data (2016–17), there were 657 private hospitals in Australia. In 2019–20, the recurrent expenditure on public hospitals was $66.4 billion, with state and territory governments and the Australian Government contributing to the funding (here, here). The expenditure continues to increase with spending per person, increasing by an average of 1.1% per year between 2014–15 and 2019–20.
In recent times, state and territory governments have lobbied the Australian Government to increase its share of funding, as demand for acute care, workforce costs, and pressures on public hospitals spiral.
The often-repeated demand in the call for funding is for extra hospital beds in public hospitals to meet growing acute care demand from the community.
So, what are these hospital beds? Are they mere furniture?
The Australian Institute of Health and Welfare defines an available hospital bed as “a suitably located and equipped bed chair, trolley or cot where the necessary financial and human resources are provided for admitted patient care”. There are alternative terms to “available beds”, including “active beds” and “base beds”, among others.
The number of available hospital beds per 1000 people in Australia in 2016 was 3.8. This represents a steep decrease from the year 2000 when there were 7.9 beds per 1000 people.
Although this decrease may seem alarming, this trend mirrors a decline in bed availability in almost all the developed countries. Health technology, changing models of inpatient care, and enhanced community-based services have all played a role in decreasing available beds. The trend in the face of renewed calls for more hospital beds is disconcerting but is there a cause for concern? Do we need more hospitals and hospital beds?
Less is more
Hospital overcrowding and the perception that this is caused by an inadequate number of inpatient beds often lead to demand for more inpatient beds by the community and clinicians (here, here, here). However, the reality of establishing a bed is complex, with the requirement to consider the workforce necessary to support the care associated with the bed (here, here, here). Further, the number of beds in a hospital is not a measure of success but merely an indicator of capacity. Even though adding beds increases the hospital’s capacity to service demand, it also adds to the ongoing expenditure.
In an environment of fiscal constraints, it is pertinent to consider if the costs of hosting a bed are sustainable and if the diversion of costs to the acute care system will lead to a shortfall in funding for other parts of the health care system.
No wonder the international trend in developed countries has seen a decrease in the overall number of hospital beds.
Evolving models of care and health technologies such as telehealth and virtual health care have led to the shift of aspects of hospital care to the community reducing the requirement of patients to stay longer than necessary in hospitals.
The COVID-19 pandemic has acutely taught us that health care systems are comprised of many interconnected points of care and that hospitals do not function in isolation. Therefore, a unidimensional approach of increasing hospital beds or building new hospitals to alleviate health care demand from the community is an inefficient and unsustainable approach (here, here, here). A multipronged approach with initiatives within and outside the hospitals is required to improve capacity to meet the increasing health care demand from the community.
Undoubtedly, one of the main contributors to emergency department overcrowding and access block is inadequate capacity within the hospital to admit patients. However, the first order solution is not always the increase in the number of hospital beds. It would be reviewing operational processes internal to the hospital, such as discharge processes (here, here).
By streamlining and expediting inpatient discharge, considerable capacity can be added to the hospital. Generally, far fewer patients are discharged on weekends, and many patients do not need to be cared for within the hospital. By reviewing these factors and discharging patients who can be cared for at home or in a subacute or community setting, bed space can be added to the hospital. Also, unused specialised beds can be converted for general or multipurpose use, adding further to the hospital’s capacity. Further, same-day discharge policies can be adapted for specific surgical procedures.
There is compelling evidence that well monitored, at-home care can be safer and more effective for eligible patients, including those at risk of hospital-acquired infections. Outside the hospital, programs such as “Hospital in the Home” (HITH), which enable patients to receive hospital-level care in their home or similar settings, have helped take pressure off hospitals and free up much-needed bed space. In Victoria, 49 HITH sites and approximately 6% of all bed days are provided through this program. Recent research has indicated that HITH patients were less likely to be readmitted and have lower mortality figures than inpatients. HITH care can be extended to many clinical areas.
From a more extensive policy context, the demand for hospital beds can be reduced by enhancing the population’s health. This can be achieved in the short term by preventing admissions and facilitating early discharge (here, here). Inappropriate emergency admissions can be avoided through medical observation units to direct patients to more appropriate settings, and non-urgent admissions can be prevented by shifting diagnoses from inpatient to outpatient settings. To enable early discharge, alternatives to hospital care, including nursing homes and subacute care, must be expanded.
In the longer term, upstream investments in preventive health programs will reduce the population’s disease burden and consequently demand acute care. Furthermore, the more effective management of many patients with chronic and complex diseases in primary care, assisted by a revised funding model to proactively manage care, will help significantly dampen demand for more hospital beds.
Conclusion
Reducing demand on hospitals and finding solutions to the current pressures on the acute care system is, admittedly, a complex process. However, to alleviate the pressure on hospitals, falling back on unsustainable and inefficient options, such as adding hospital beds, needs to be questioned.
With programs such as HITH and emerging health technologies, some aspects of currently delivered acute care can be delivered outside hospitals. Also, better managing demand and streamlining discharge processes ensuring efficient use of hospital space can increase hospital capacity without recourse to additional hospital beds. Therefore, these measures must be deliberated carefully before adding more beds to the acute care system.
Associate Professor Sandeep Reddy is the Director of the MBA (Healthcare Management) program at Deakin University. In addition to a medical degree, he has qualifications in medical informatics, management, and public health. He has managed various health service projects and formulated high level policy in Australia, New Zealand, and Europe.
Professor Grant Phelps is a gastroenterologist and acute physician in public and private practice in regional Victoria. He is a Professor with Deakin’s Medical School where he has taught into the MBA program. He is President and Chair of Hepatitis Australia.
Affiliate Associate Professor John Rasa is Unit Chair Healthcare Financing in the Faculty of Health at Deakin University.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Checking the data source for the fall in beds per 1k, this appears to be a typo as the beds fall from 7.9 (not 79) in 1999 to 4.0 in 2000. Is this correct?
The bed access block doesn’t just come from inefficient discharges or not sending people to HITH. We (orthopaedics) have many patients taking up beds and patients sitting in day surgery who are constantly bumped day after day because of lack of theatre access. Increasing emergency theatre operating time would definitely improve bedflow through most surgical specialties.
FULLY AGREE WITH JOHN DE CAMPO
Yes another article written by academics not at the coal face of either general medicine or emergency medicine or subspecialty medicine.
1. HITH refuses to take any patient remotely complex (my experience across 4 health services and 2 states. This service in my opinion exist to take patients with “ cellulitis” (hint they are not even sick and should just be sent home on orals or told they don’t have cellulitis at all they have billateral venous stasis from non compliance with fluid restriction/diuretics), often I find they don’t even have cellulitis and the service is used to entertain the whims of certain patients who have no insight in to the fact they do not have an acute problem at all) and then do a homeopathic treatment of 2 gram cefazolin per day with some probenecid which is a joke compared to proper oral Antibiotics. They then have “better outcomes” because they only take on the walking well. “Reduced mortality” “Less DVT” “Better patient satisfaction” come on.
2. If HITH took on far more cases there would be unlimited demand. Instead of 1 patient sitting in hospital waiting for an MRI for a soft story for Cauda Equina (yes a waste of money but a good example) there would be an additional 6 in HITH if it was used like that. Then we would all discover the fundamental problem NOT ENOUGH FUNDING FOR ACTUAL MEDICAL NEED LIKE AN EXTRA MRI MACHINE. It would be overrun in the same way outpatient services are already overrun. It would be filled with the patients who have legitimate complaints regarding wait list issues (Waiting for TAVI but SOB, Waiting for joint replacement but has pain, waiting for electrophysiology studies but still has palpitations, waiting for follow up MRI, waiting for Neuro opinion, waiting for surgical review of hernia but still has pain, waiting for cystoscopy but still has haematuria. If all this stuff was sent to HITH we would have no money left to spend on the actual doctors that do actual medicine. HITH is a way to siphon money away from actual clinical care.
3. It is not cheaper- Nurse goes to like 3 patients per day. They then call some doctor which no information, they then send the patient to Ed (this is assuming the patient is actually mildly sick) of course the ones who should never have been on HITH in the first place (which is 80% of HITH patients) at all won’t get sent into ED and they will contribute to the Stats that builds the lie that HITH achieves something.
4. Fund the advanced trainees and middle tier registrars properly these are actually doctors who make actual decisions and can actually run a hot clinic where the patient can visit every day. If the patient cares about their health they will come. If the patient is too old and frail they phone review can occur for appropriate cases. In my experience a well run service (such as renal) who knows their patient, has OPD and uses it properly has better care and prevents admission. General medicine through a “MAU Model” (another brain child of academics) who just get people out quick for “GP follow up” have lead to this crisis.
5. Stop funding “project officers”, business consultants, nurse navigators, physician assistance (except in very specific scenarios where it is clear they have benefit- 80% of the current is just unionist positions let’s be honest). All this does is make the patient angered that they speak to 5 people and 8 hours later the 5th person knows what they are talking about (Medical registrar, ED consultant, EDregistrar, SHO)
Thanks Sue. That made a lot more sense than the main article.
Share the risk. Maintain the flow. Expand the options.
But if its not working… more beds needed.
Thanks for an important article. In addition to the points made, I would add the following: there are a number of dysfunctional feedback loops and blocks to flow that result in hospital emergency department overload. So long as the ED front door remains open, but the back door (to the wards and ICU) remains closed (unless a bed is immediately available), EDs will always be dysfunctional and we will see the frustration as expressed before by my (anonymous) colleague.
We should learn some important lessons from the COVID era that represent improvements on the previous normal. First, don’t default to ED to solve all gaps in other social, health care and custodial problems – that impairs the ability of EDs to provide safe and high quality acute care.
Second, continue to provide telemedicine and care at home (monitored by phone calls and visits, with oximetry) at every opportunity – hospital care is commonly not better and may be more dangerous. We need to communicate this as providing better care, not depriving the person of the hospital service. This is particularly important for residents of aged care facilities and their families – we don’t want to “deprive” them of the ambulance trip to ED in the middle of the night – we want to SAVE them from the delirium, cold and hunger that is likely to result from the transfer.
Third, and perhaps most importantly, clinical workload and risk needs to be shared across the community, ED, wards and ICU – with compromises made rationally at every stage. It is not acceptable to concentrate both excess workload and risk in EDs – this harms patients and burns out clinicians.
Finally, we must drive flow out of ED and into wards/ICU by locating the excess admitted patients OUT of ED. Inpatient units MUST take responsibility and care for the patients admitted under their care. The excess patient load must be located on the inpatient side of the hospital, within view of the inpatient teams, and with an incentive to accommodate them (rather than leave ED to house all the incoming patients AND the admitted patients awaiting beds). Are beds blocked by patients who can’t get back out to community care? This has to be solved – use medi-hotels or other models developed for COVID. No more excuses – move to action,
So long as flow is blocked, there will never be “enough” beds. Building and staffing more beds takes the incentive away for improving flow. What stifles creative problem-solving is when there is no palpable incentive to change the system.
I sit firmly in the “less is more” camp – less concentration of workload and risk in ED, less unproductive tests and referrals, less holding of patients in expensive acute beds due to failure to create alternative choices, and MORE focus on real patient needs, explanation and caring. Those factors don’t need more beds.
boy, how many times have I been told that Hospital in home, Inreach services and community based care will keep people out of our hospitals ?
as an Emergency physician confronted every single day by chaotic, overcrowded, ambulance ramped, bed blocked hospital ermergency departments bursting at the seams, with waiting rooms of 30+ people to be seen but no cubicle space available to see them, and 8 or 10 ambulances lined up unable to be offloaded, with the problems getting worse and worse every year, I am appalled at any suggestion that we can do with fewer hospital beds.
get out of your ivory tower and have a look at the real world us clinicians are drowning under.
Thanks for collecting the data. Denmark, not a backward society CLOSED two thirds of all its hospitals over the past 20 years. All we lack is leadership.
Haha, you seem to forget we ARE practising “the 21st century practice of medicine”. We have had MANY business consultants, efficiency experts etc come through our hospital over the last decade to try to squeeze a little more out of every bed. Absolutely no improvement resulted. Only decline. Quoting “emerging health technologies” is a bit like claiming we will reduce global warming with future technological advances. What do you expect our hospital staff to do until your mirage is exposed?
Until budgets for all levels of the health system come under control of the same level of government there will be no motivation for correctly balancing primary, hospital, and aged care resources.