Beds numbers in England by STP - BMA
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Beds numbers in
England by STP
This paper explores the fall in the number of beds in the NHS
in England, as well as the relationship between bed numbers
and key NHS targets such as A&E waiting times. It sets out
evidence based on the available data of the relationship between
beds and performance at a regional level, and makes several
recommendations for the NHS to follow.
British Medical Association
bma.org.ukBritish Medical Association Beds numbers in England by STP 1
Introduction
The winter of 2017/18 has been widely acknowledged as the most pressurised in the history
of the NHS in England, with A&E departments struggling to cope in the face of enormous
demand and limited capacity.
This period of intense pressure, with general and acute bed occupancy over 90% for all but
four days this winter, has highlighted how important bed capacity is to the ability of the NHS
to withstand peaks in demand and the risk that reductions in that capacity may present.1
There is concern across the NHS that pressures are outstripping bed capacity, with the
NHS’s own leaders recently suggesting that a minimum of 4,000 extra beds are needed if the
health system is to get through next winter.2 Moreover, recent BMA research has found that
winter pressures may even extend right through summer, with forecasts showing a best-
case scenario for July, August and September of 2018 comparable to the winter of 2015.3 The
announcement that the University Hospitals of North Midlands NHS Trust has extended the
use of its additional winter beds through to the summer of 2018 supports this analysis, and
illustrates the scale of the challenge facing the NHS.4
As the BMA has previously highlighted, bed numbers in the English NHS have declined
significantly in recent years. In 2000 there were an average of 3.8 beds per 1,000 people
in England, but by 2016 this had fallen to 2.4 beds. Between Q2 of 2010/11 and Q2 of
2016/17 the number of overnight beds fell by 14,000.5 Although reducing hospital beds can
sometimes be appropriate, this reduction has coincided with a period of both significant
financial pressure in the NHS and a growing system-wide inability to meet key targets. For
example, in March 2018 four-hour wait performance at all A&Es was 84.6%; the worst figure
on record.6
Despite this longstanding pressure on the system, many STP (Sustainability and
Transformation Partnership) plans, which were launched in order to deliver the NHS FYFV
(Five Year Forward View) and are intended to transform health and care in England, included
an intention to cut bed numbers when they were first published.7 Although those plans have
since been rebranded as ‘works in progress’ by NHS England and may not be implemented
as written, there remain significant concerns regarding the priorities of the STP programme
and the viability of individual STPs’ planning in respect of bed capacity. Furthermore,
given the increasing role of STPs in health and care planning, as set out in the 2018/19
NHS planning guidance, it is essential that data on bed numbers and performance is both
available and interrogated at an STP-level.8
On that basis, this paper explores the relationship between bed numbers and key NHS
targets such as A&E waiting times, by:
–– p roducing a historical analysis of how bed numbers have changed at STP footprint level
(the overall geographical area of each STP), looking at variation in how some areas have
chosen to increase or cut bed numbers in recent years in the context of national changes
in bed numbers between 2014/15 (prior to the creation of STPs themselves) and 2017/18
–– assessing the relationship between changes in bed numbers and performance against
national targets, such as A&E waiting times
–– analysing what assessments STPs have made of bed capacity in their locality and what
plans they have for the future, based on BMA freedom of information (FOI) requests
Our research looks specifically at bed numbers across the NHS Trusts in each of the 44 STP
footprints between 2014/15, when the FYFV, was launched, and 2017/18.a In conjunction
with this data analysis we also submitted FOI requests to each STP, requesting details of both
their assessment of bed capacity in their footprint and of any plans they may have to reduce
bed numbers.
a In this context, STP footprint refers to all of the NHS trusts located within each STPs geographical area and not
to the STP as an individual body. Please see the technical note for more detail on this analysis.2 British Medical Association Beds numbers in England by STP
Our analysis has revealed that:
–– b eds have reduced by an average of 140 per STP footprint since 2014/15 – a fall of over
6000 at a national level
–– bed numbers have decreased in 29 of 44 STP footprints since 2014/15
–– the largest decrease in bed numbers amongst STP footprints was 21%, whilst the largest
increase was 22%
–– the 10 STP footprints that experienced the largest reduction in bed numbers also saw the
most rapid deterioration in performance
–– all but 3 STPs have said they have no plans to reduce bed numbers, in many cases
showing significant divergence from their original plans
–– several STPs appeared not to have carried out any analysis of the bed capacity across
their health system
–– projections suggest that by 2019/20, there will be approximately 125,000 beds in the NHSBritish Medical Association Beds numbers in England by STP 3 Background In March 2016, England was divided into 44 geographic STP footprints, each of which brought together hospitals, CCGs, GPs, local authorities and other health and care providers with the objective of producing collective plans for the future of health and care services in their area. STPs are intended to deliver the NHS FYFV and, importantly, to achieve financial balance by 2020. Although STPs and their footprints are central to NHS England’s vision for the future of the NHS, data reporting and analysis has been slow to adapt to this. Performance data has only recently been provided at STP footprint level and, as outlined in this report, bed data is still only available for individual Trusts. Therefore, given the importance of STP footprints, it is imperative that data is provided and examined at this level, for both before and after their creation. In their initial plans, a significant number of STPs proposed reducing bed numbers and shifting care into the community and general practice as a means of achieving financial balance and delivering the FYFV. This was highlighted in the BMA report Delivery Costs Extra, as were our strong concerns about any loss of beds without significant prior investment in community care, and the evidence base for this approach generating financial savings.9 The BMA has also been critical of the way the STP programme has developed nationally. One of our primary criticisms has been of the severe lack of transparency surrounding the process and the absence of consistent clinical and public engagement in many areas. This has been a particularly acute problem in respect of planned bed closures and service reconfiguration. Although bed closures are subject to rules on public consultation, and NHS bodies are now required by NHS England to pass a test for any proposed bed cuts in respect of their impact on patient care, there remains significant confusion in many areas regarding bed planning at an STP level.10 The lack of substantive public engagement by many STPs on their plans, even in cases where proposed bed reductions are no longer being pursued, has meant that many doctors, NHS staff, and the public remain concerned and uncertain about the implications those plans may have. As a result, it is important that future plans STPs might have in relation to bed numbers are transparent and made public.
4 British Medical Association Beds numbers in England by STP
Data
Beds in the NHS
It is a well-established fact that the NHS has cut a substantial number of beds in recent
years. The 2017 BMA report, State of the health system – Beds in the NHS, examined the
implications of and reasons behind cuts to beds. The report found that reductions in the
length of inpatient stays, better primary care and a general shift towards preventative and
community care mean that fewer overnight beds are needed, but that hospital beds remain
a core component of the health system and the recent decline in bed numbers remains a
major cause for concern.
Since 2010, the number of overnight beds in the NHS in England has decreased by over
14,000, in which time the average bed occupancy figure has increased by 3% (in the most
recent data, occupancy of all beds was 88.4%).
Figure 1: Available beds and bed occupancy
150,000 90%
80%
145,000
70%
140,000 60%
50%
135,000
40%
130,000 30%
20%
125,000
10%
120,000 0%
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
All beds Total occupancy
The available data also indicates that the rate of bed cuts is accelerating. Between 2011/12
and 2013/14, the NHS cut 3,400 beds, or 2.5% of the available bed stock; between 2013/14
and 2017/18, 6,200 beds (4.6%) were cut.b Using an average rate of decline from the past
eight years, projections suggest that by 2019/20, there will be just over 125,000 beds in the
NHS in England. With most trusts approaching (or even exceeding) occupancy figures of
95% for much of the most recent winter, it is increasingly hard to see how hospitals can be
expected to cope with seasonal increases in demand as many of them enter each new winter
with fewer beds than they had the previous year.
Using historic data and STP footprint boundaries, we calculated which parts of England
saw the most substantial cuts. Our analysis has examined changes to bed numbers across
individual STP footprints, collating data from the individual NHS trusts within those areas in
order to present a system-wide figure.
b Comparisons are between Q1 of 2011/12 and Q1 of 2014/15, and Q1 of 2014/15 and Q1 of 2017/18British Medical Association Beds numbers in England by STP 5
Findingsc
Across all 44 STP footprints, the largest reduction was 1,282 beds, whilst in a few cases the
number of beds rose (the largest increase was 302 beds). On average, 140 beds have been
lost per STP footprint.
Figure 2: Top and bottom 10 STPs by proportional changes in bed numbers
Lincolnshire -21.0% Dorset 21.7%
South East London -18.0% Cornwall and the Isles of Scilly 14.5%
Leicester, Leicestershire and Rutland -17.6% Milton Keynes, Bedfordshire and Luton 9.0%
Somerset -15.8% Birmingham and Solihull 6.2%
Greater Manchester -15.4% Frimley Health 5.7%
South Yorkshire and Bassetlaw -15.1% Northamptonshire 5.1%
Staffordshire -13.5% South West London 4.6%
Hertfordshire and West Essex -11.6% Sussex & East Surrey 3.0%
Mid and South Essex -9.3% Bristol, North Somerset and South 2.9%
Gloucestershire
The Black Country -8.9% Suffolk and North-East Essex 2.3%
The data shows significant variation across England in the extent of cuts to beds;
Lincolnshire saw a decrease of 21% in its number of beds whilst Dorset saw its bed stock
increase by almost 22%. Across the whole country, the average decrease was 3.6%. 14 STP
footprints increased their bed stock (by an average of 5.7%) against 30 that saw decreases
(by an average of 7.9%).
Targets
An increase in pressures and demand between Q4 of 2014/15 and Q4 of 2017/18 is
consistent across almost all STP footprints. In this period, the average increases per STP
footprint in attendances at A&E and emergency admissions were 9% and 12% respectively,
while performance against the four-hour wait deteriorated from an average of 91.3% to
84.6%. Trolley waits of four or more hours increased from an average of 2,583 to 5,131 per
STP footprint, while twelve-hour trolley waits went up from 22 to 52.
There are several notable differences in performance between STP footprints that have
either gained or lost beds. Performance has deteriorated in the latter at a faster rate, though
those that have gained beds have seen demand increase at a faster rate.
In STP footprints that gained beds, the proportion of patients seen, discharged or admitted
within four hours fell by 5.9%. In those that lost beds, the figure fell by 8.0%. Similarly, even
after the exclusion of two major outliers,d four-hour trolley waits increased by 84.3% in
footprints that gained beds compared with 106.3% at those that lost them.
c Unless stated otherwise, data comparisons are between quarter three of 2014/15 and quarter three of 2017/18
– averages are taken from performance figures for individual STPs
d Lincolnshire and Somerset lost 17.6% and 21% of their beds, and saw four-hour trolley waits increase by 7578% and
1870% respectively.6 British Medical Association Beds numbers in England by STP
Figure 3: Trolley waits and performance against the four-hour wait target
140% 10%
9%
120%
Percentage deterioration in four-hour
Percentage change in trolley waits
8%
100% 7%
wait performance
6%
80%
5%
60%
4%
40% 3%
2%
20%
1%
0% 0%
Gained beds Top 10 gainers Lost beds Top 10 losers
STPs
Trolley waits of four or more hours
Percentage of emergency admissions ending in trolley waits of four or more hours
Four-hour wait performance
Whilst pressures and performance are determined by a much larger number of overlapping
issues, beds remain an important facet of healthcare delivery. The only period of the year in
which the number of beds consistently increases (winter) sees the highest levels of pressure,
but demand and activity increase every year (attendances at A&E increased by an average
of 1.7% per year between 2011 and 2017, while emergency admissions increased by 2.6%
per year); in the same period, the number of beds fell by almost 10,000, and bed occupancy
increased to unprecedented levels.
The Nuffield Trust has calculated that based on increases in activity and population size,
the NHS is liable to require an additional 10,700 beds in the coming years, rather than further
reductions (a figure which also imagines trusts running at 100% occupancy, which would
be impossible in practical terms, so the real number is liable to be even higher).11 Clearly,
then, bed numbers continue to play a vital role in ensuring that patients have timely and
safe access to quality care.
STPs: beds and future plans
Our 2017 report, Delivery Costs Extra, found that almost all STP plans prioritised improving
prevention and shifting care into the community. In many cases this was in conjunction
with plans to reform the provision of acute and community hospital services, including
reductions in bed numbers. Most plans were also explicit that these changes were intended
to not only reduce hospital activity, but to also deliver financial savings – despite significant
evidence challenging the concept that shifting care into the community generates major
savings.12
Therefore, alongside our data analysis, we also submitted FOI requests to all 44 STPs, to establish
what assessment each had made of its overall bed capacity and whether they have any current
plans to reduce it in the future. Specifically, we requested the following information:
–– t he number of available overnight and day beds at trusts within their footprint counted as
part of the STP’s planning
–– the number of available community beds
–– any plans to reduce or increase the number of beds within the footprint by 2020/21
–– any reviews, consultations or impact assessments pertaining to changes in bed numbersBritish Medical Association Beds numbers in England by STP 7 Of the 44, 32 responded directly to the request. Of those 32, all but 11 argued that there were grounds to exempt the information as the number of beds within STP footprints could be calculated using NHS England data. Of the 11 that did respond with bed numbers, just three discussed plans to change the number of beds within their footprint. The vast majority of STPs responded that there were no plans to change the number of beds at trusts as part of the local plan. Although several STPs provided us with detailed breakdowns of their current bed stock, as well as plans for further changes to bed numbers, in most cases STPs provided neither. Given the nature and purpose of STPs, and the fact that many plans involve major changes and reconfigurations of local services, proper engagement and transparency is essential. However, most STPs directed us to an NHS England dataset that does not include an STP breakdown and required a separate exercise to match trusts to their relevant footprint in order to calculate the number of beds within an STP. Moreover, whilst A&E data is now published at STP level, most other datasets are published only at national and trust level, a situation which should be addressed by NHS England as soon as possible. Secondly, a number of STPs responded that they had not yet assessed the number of beds within their footprint, or within each of their constituent Trusts. These included the West Yorkshire and Harrogate STP and the Frimley Health and Care STP, which was rated ‘outstanding’ in the NHS England progress dashboard. The BMA remains concerned that many STPs, including the most advanced, are unable to share an assessment of their local health assets. Thirdly, whilst several STPs clarified that local plans did include bed closures, and offered information on the extent and underlying rationale for these cuts, the majority suggested that there were no plans to close beds at trusts in the footprint. However, as clarified in this report, in 29 of the 44 STP footprints bed numbers have reduced over the last three years, in some cases very dramatically, and the likelihood that there are no further closures to come seems extremely slim. Several STPs also have plans to conduct reviews of their acute services which, depending on their outcome, may generate plans for future reductions in bed numbers within certain STPs. STPs and Community Care As noted above, many STP plans included references to bed cuts on the basis of shifting care into the community. In this context it is important to be clear that reducing bed numbers is not inherently a problem in all cases. However, it is vital that any reductions in bed numbers are evidence-based and subject to thorough review, impact assessment, and engagement with clinicians and the public. It is also essential that any plan to transition care from hospitals to community and GP settings is properly funded and that those services can develop to safe levels before hospital capacity is cut. This evidence, engagement and investment has not been forthcoming. Additionally, despite calls from the Kings Fund for STPs to revisit their plans for community care and for a national strategy for community care,13 NHS England has since abandoned plans for a ‘Five Year Forward View for Community Care’.14 This decision has been criticised by Bill Kirkup, author of the recent report into the state of care at Liverpool Community Health Trust, who has argued that efforts to sustain growing workloads with reduced capacity presents a genuine risk to patient safety and quality of care.15 There are, therefore, significant questions surrounding the basis upon which many STPs built their initial plans for reconfiguration, and the current capacity of alternative services to compensate for any further reductions in hospital beds. If STPs continue on the current trajectory of decline in bed numbers, let alone proceed with further cuts, there must be a clear strategy for doing so and sufficient time and resources provided to community and primary care to compensate for the increased demand this will generate.
8 British Medical Association Beds numbers in England by STP
Conclusion
The English NHS is enduring the most intense period of pressure in its history, amid
underfunding, system transformation, and, as our analysis shows, a significant lack of
capacity to handle growing demand.
Our analysis of bed numbers within STP footprints reveals that there is an historic and
ongoing decline in bed numbers across England, and that this has continued within the
majority of STP footprints. Moreover, we have found that where that decline occurred most
quickly, performance also deteriorated at the fastest pace.
In addition, our FOI requests to each of the 44 STPs revealed a lack of understanding within
STPs themselves of the total number of beds available in their area, and that, in contrast to
the proposals within many of the initial STP plans, very few have active plans to reduce bed
numbers. While the shift in focus away from bed cuts is welcome, the lack of willingness,
or ability, to share details of bed numbers in many STPs is seriously concerning and
underscores the BMA’s ongoing concern regarding the transparency of STPs.
Considering our findings, we have four recommendations that we believe need to be
followed to ensure that pressures on the NHS are reduced, that patients can access services
swiftly, and that doctors are able to provide the best quality of care possible. These are:
–– t he Government should report on bed numbers on a regular basis at an STP level, making
this information easily accessible to the public
–– that the proper resources, planning, and time are dedicated to enhancing care and
capacity in the community, if they are expected to absorb greater demand
–– all STPs should be required to assess their bed needs over 5-10 years, publishing their
findings
–– as further cuts to beds are likely to exacerbate pressures, which have already reached
historic highs, no further bed cuts should be planned until key targets can be reliably met
and sufficient capacity within the community is established
–– as part of any future long-term plan for health and social care services, the government
should prioritise restoring bed capacity in the NHS to a level considered appropriate by
cliniciansBritish Medical Association Beds numbers in England by STP 9 Technical Note The analysis in this report includes data from before the creation of STPs in March 2016 and is not linked to information provided by STP bodies themselves. It also does not necessarily reflect actions taken or planned by any STP. In the context of this analysis, ‘STP footprint’ refers to the geographical area of an STP and to the individual services within it, not to the STP as an organisational body. In terms of historical data, the division of the country into different STP footprints provide a useful blueprint to analyse cuts at local levels, but as STPs also represent the main driver of future changes to NHS services, their role in future cuts to beds will have to be considered. More recent data implies that the number of available beds in England is falling at an accelerating rate. It would be impossible to establish a causal link between this and the introduction/implementation of STPs, but it is important to contextualise further cuts and reconfigurations in local services.
10 British Medical Association Beds numbers in England by STP
All STPs
Bath, Swindon and 1.8% Birmingham and 6.2% Bristol, North 2.9%
Wiltshire Solihull Somerset, South
Gloucestershire
Buckinghamshire, -7.7% Cambridgeshire and -0.3% Cheshire and 2.3%
Oxfordshire and Peterborough Merseyside
Berkshire West
Coast, Humber and Vale -2.7% Cornwall and the Isles 14.5% Coventry and -2.6%
of Scilly Warwickshire
Derbyshire -8.1% Devon -3.1% Dorset 21.7%
Durham, Darlington -6.6% Frimley Health 5.7% Gloucestershire -2.0%
and Tees, Hambleton,
Richmondshire and
Whitby
Greater Manchester -15.4% Hampshire and the Isle -2.8% Herefordshire and -8.1%
of Wight Worcestershire
Hertfordshire and West -11.6% Kent & Medway 0.9% Lancashire and South -5.8%
Essex Cumbria
Leicester, Leicestershire -21.0% Lincolnshire -17.6% Mid and South Essex -9.3%
and Rutland
Milton Keynes, 9.0% Norfolk and Waveney -1.9% North Central London -8.3%
Bedfordshire and Luton
North East London -3.7% North West London 2.4% Northamptonshire 5.1%
Northumberland, Tyne -7.0% Nottinghamshire -7.7% Shropshire and Telford -1.9%
and Wear and Wrekin
Somerset -15.8% South East London -18.0% South West London 4.6%
South Yorkshire and -15.1% Staffordshire -13.5% Suffolk and North East 2.3%
Bassetlaw Essex
Surrey Heartlands -8.3% Sussex and East Surrey 3.0% The Black Country -8.9%
West Yorkshire 0.6% West, North and East -4.6% Average -3.6%
CumbriaBritish Medical Association Beds numbers in England by STP 11
References
1 House of Commons Library. NHS Winter Pressures in England, 2017/18. April 2018.
Available at: parliament.uk
2 Health Service Journal. NHS ‘at least 4,000’ beds short for next winter. April 2018.
Available at: www.hsj.co.uk
3 British Medical Association. BMA analysis shows winter pressures extending right through
summer. April 2018, Available at: www.bma.org.uk
4 Health Service Journal. Trust extends winter pressures plan until Summer. March 2018.
Available at: www.hsj.co.uk
5 BMA. State of the health system – Beds in the NHS. December 2017.
Available at: www.bma.org.uk
6 NHS England. A&E Attendances and Emergency Admission 2017-18.
Available at: www.england.nhs.uk
7 Kings Fund. NHS hospital bed numbers: past, present, future. September 2017.
Available at: www.kingsfund.org.uk
8 NHS England and NHS Improvement. Refreshing NHS Plans for 2018/19. February 2018.
Available at: www.nhsengland.nhs.uk
9 British Medical Association. Delivery Costs Extra: can STPs survive without the funding
they need. June 2017. Available at: www.bma.org.uk
10 NHS England. New patient care test for hospital bed closures. March 2017.
Available at: www.england.nhs.uk
11 Nuffield Trust. Will the NHS really need fewer beds in the future? August 2017.
Available at: www.nuffieldtrust.org.uk
12 London Southbank University. Sustainability and Transformation Plans: How serious are
the proposals? A critical review. May 2017. Available at: www.lsbu.ac.uk
13 Kings Fund. Reimagining Community Services. January 2018.
Available at: www.kingsfund.org.uk
14 HSJ. NHS England abandoned ‘forward view’ for community services. February 2018.
Available at: www.hsj.co.uk
15 HSJ. Kirkup warnings over scrapped community services ‘forward view’. March 2018.
Available at: www.hsj.co.uk12 British Medical Association Beds numbers in England by STP
British Medical Association BMA House, Tavistock Square, London WC1H 9JP bma.org.uk © British Medical Association, 2018 BMA 20180428
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