The current crisis in the NHS is wearingly familiar. There is talk of patients waiting, and occasionally dying, on trolleys before being admitted, ambulances waiting for hours outside hospitals with paramedics before A&E have the space to take over their care, flu epidemics; too many elderly patients with complex conditions becoming ill over the winter periods, patients in hospital who have been treated and could now go home except there are no services available for them to go home; and so on. It seems to happen every year, and every year there is a crisis.
Looking back on a lifetime of being a GP, I can remember (just) a time when this didn’t happen. If you were on call in the 70’s you were very busy seeing acutely ill people, and they were definitely younger, fitter, and would need a week or two in hospital to be treated for their pneumonia, heart attack or acute gastric ulcer (anyone remember that?), and would then go home to their family. Ambulances arrived, not always very quickly and without paramedics, and discharged their patients straightaway into hospital, and there was very little problem with discharging people. There were council-run care homes for the few that needed them.

So what caused the change?
Yes, the population has increased substantially, but undoubtedly it was the very success of medical treatment that made the real difference. To fail to save someone’s life was a tragedy, but it was a cheap outcome. To succeed, on the other hand, was a wonderful achievement and we were all thrilled, but it was very expensive. As each generation went on to survive into their seventies eighties and nineties, people continued to consume medical resources, collecting diseases (now renamed long term conditions), but still surviving. For some individuals, treating these conditions resulted in a near normal life, but others became severely disabled to the point when no spouse or daughter (hardly ever a son) could look after them. Hence the gradual proliferation of care homes, social services help and so on, all costing an awful lot of money provided by the state for those who could not afford to themselves. You would have thought that hospitals too would be proliferating with more and more hospitals being built to cater for the huge increase in treatments available. But all over the world the cost of medical care was rising to a level above that which countries were willing to pay for, and by the early nineties the system was already creaking. The brakes had to be put on somehow.

It was recognized very early that hospitals were the really expensive part of health care, and that they should only be used when absolutely necessary. My older patients in the seventies would talk of “going into hospital for a rest” when things got tough for them, and sometimes it actually happened! As early as the late eighties, health economists in the USA and Europe, with very different methods of providing health care, were working out ways in which bed occupancy could be cut despite the fact that hospital beds used to be the most prized and economically profitable part of their health systems. Hospitals would have to become lean and mean; very efficient at processing their clients and ruthless in pushing them out again.

So fast forward to 2006. After 33 years as a GP in a market town in Wales, I took a job as acting Medical Director of the local Health Board. At that time, it was clear that the old model of district medical hospitals providing care for a local population was creaking badly; so there were plans to build a large super hospital, a Specialist Critical Care Centre, to take over some of the more complex cases. I was immediately thrust into meetings, which were set up to do detailed planning for this.

Hence I was introduced to the concept of “Virtual Beds”. What is a virtual bed then? You may well ask, as there was no clear answer. What it should mean, I was told, was that instead of a hospital having say 400 beds, it could have 320 beds plus 80 virtual beds. Those “beds” represented the cost envelope for the care of the patients who could be cared for in other environments, such as day care, a care home, or, most sought after of all for these planners as it was the potentially the cheapest, the patient’s own home, with staff going in to look after their essential needs. So our job was to price the resources in these other “facilities” and sell it to the public that these “beds” equated to the beds currently in the local hospital. In this way the new hospital could create new beds, but the old beloved DGH would lose far more beds than were created by the new one. A private company was contracted to work out the detailed development and costing of this new model, and they produced wonderful large spreadsheets in which you could put in the number of beds, the cost per bed, number of staff trained to various levels, and so on, so that the ultimate solution would have as few actual beds and as many virtual ones as possible.

The “science” of health economics was therefore quite well developed 10 years ago, but the problem has been actually implementing the ideas. There have been successes in that more and more beds have been successfully cut, because they really weren’t needed, and so considerable amounts of money have been saved and the system made more efficient.

But for me as a GP looking at their plans, there was one big flaw in their costing. They were assuming that the older, sicker patients, such as the old lady who had had a stroke, or the 90 year old person with diabetes, early dementia and recurrent falls, and so on, did not need super specialist care and could easily be shunted into “beds” with lower staffing levels and so consume less in the way of “resources” i.e. money. Although that sometimes may well be the case, as a GP I knew very well that these people did not have stable illnesses, where the level of care that they needed could be planned in advance, implemented and the cases closed. These are very often people in the trajectory of the end of their lives. It is well known that for every individual in the UK the last two years of their lives will incur about 90% or more of the total spend of the NHS on their care. And it will accelerate until they die. These people oscillate from needing social care only, to needing very complex medical interventions in high tech units urgently, and this goes on for months, may be for years. Virtual beds do not even remotely provide an answer to this problem. You will still need the facilities of the big hospital for everyone, especially the elderly. And even if technically you can get them out of hospital quickly and easily, often the cost of doing this approximates the cost of treating them in real beds.

But the virtual bed concept did have one thing going for it. A “bed” is not just a bed. It represents the costs attached to that bed and a very big part of that is the cost of the staff that treat and look after the patient. Cut that cost envelope too far and you have real trouble. In times of high demand, you will get all the problems we have now – long waiting times in A&E, people treated on trolleys, bed-blocking, (then called DTOCs – delayed transfers of care), ambulances stuck outside hospitals, and so on.

The solution has to involve more money. Any modern system has to have access to money that can make the entry to hospital and discharge from hospital a priority, by having flexible access to fully staffed beds, which will go up and down with demand. Money that can be conjured up really quickly; task forces that will go into hospital buildings, open wards that may have not been needed in the summer, and provide the treatment that these frail elderly people are going to need. It wouldn’t be easy – you need to right skill mix of staff to do this, and staff can lose skills very quickly, so continual learning and updating is essential. But when we have bed occupancy of 95% or more, as we do at the moment in the UK, we have already cut the number of permanent beds too far in my view.

There is no doubt in my mind that part of the problem with political management of the health services is that health economists’ forecasts of what can be done with efficiency savings, lean management systems and so on are far too rosy. Basically they don’t understand how and when people get ill.

And what happened to our brand new hospital? When I left the organisation, planning had been put on hold. Funding of £350m was finally confirmed in 2016, and building started in 2017, 11 years after I was involved in the planning.
Originally it was to have 505 beds, but the final total is 471 beds. There will be reductions in numbers of beds in the surrounding hospitals and I take it this also will mean a lot of virtual beds. It will open (they say) in Spring 2021. I do hope all those spreadsheets had been dusted off and calculations done so that this hospital, and others like it in the UK have the correct number of actual and virtual beds, so that in the future patients on trolleys now can have an actual bed when they most need one.