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  1. Politics
17 January 2000

It’s not the flu that ails our NHS

If there's a shortage of hospital beds, that's exactly how health service managers have planned it

By Theodore Dalrymple

The government says there is a flu epidemic, the opposition says there isn’t. It all depends, apparently, on the numbers of cases per 100,000 of the population. We begin to see the attractions of the dispute about how many angels may dance upon the head of a pin. It is enough to say that it is easier for a camel to go through the eye of a needle than for a man with an inguinal hernia to enter into the kingdom of an NHS surgical bed.

The government wants there to be a flu epidemic because it would explain the current shortage of beds in the NHS. The opposition wants there not to be a flu epidemic so that the bed shortage is not thus explicable. But everyone knows that if the government were the opposition, and the opposition were the government, they would be arguing precisely the opposite of what they are now saying. This is a powerful tribute to the iron integrity and intellectual honesty of our politicians, as well as to their determination to put the welfare of the people above all other considerations. Medical care is safe in politicians’ hands.

Actually, the whole question of whether there is or isn’t a flu epidemic is beside the point. If there is such an epidemic, it needs to be remembered that such epidemics are to be expected: they are a regular feature of human life. And if there isn’t an epidemic, it needs to be remembered that the NHS doesn’t require one for there to be a bed shortage: for such shortage is a regular feature of the NHS.

Indeed, for many years the creation of bed shortages has been a sign – perhaps even the sine qua non – of managerial efficiency in the NHS. An empty hospital bed has been to NHS management what garlic flowers and holy water were to Dracula. All hospital beds must be occupied at all times, otherwise there was waste.

I remember the days 20 years ago when the Hospital for Tropical Diseases was threatened with closure. The doctors working in it used to keep their patients in its beds longer than strictly necessary to ensure the high bed-occupancy rate that alone would persuade the government that the hospital’s existence was necessary and justified. An empty bed was a sign of a redundant institution.

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Since then, the mania for cutting beds has proceeded apace. In part, this has been dictated, or at least made possible, by advances in medical techniques. Bed rest for weeks on end is no longer prescribed for cases of heart attack (still the single most common cause of emergency medical admission to hospital); rather, immediate mobilisation is; and surgical patients recover from their operations far faster than they used to.

On the other hand, an ageing population requires more medical treatment than ever, and conditions that were once inoperable or otherwise untreatable now require hospital treatment.

Constant hospital bed shortages have unpleasant consequences for medical practice, both from the doctors’ and patients’ point of view. The patient who presents himself to hospital in an emergency is expected to wait for several hours (and sometimes longer) in humiliating conditions while a bed is found for him; patients who arrive in hospital to be admitted for routine, non-emergency treatment find, as often as not, that their treatment has been postponed and their bed taken by someone with a more urgent problem than theirs. It is not uncommon for this to happen three, four or five times before the routine treatment is finally given.

For the doctor working in such a situation, there is little more nerve-wracking or soul-destroying than the constant juggling of beds he is forced to resort to when trying to admit desperately ill patients.

Sometimes he has to discharge someone from hospital who is not really ready yet for discharge, but nevertheless represents the least unready person under his care, in order to accommodate a new patient. When the discharged person returns to hospital with a complication that results from his too-early discharge, the hospital can pride itself on its efficiency, because it can then claim to have treated two episodes of illness instead of one.

Pressure on beds means that doctors cannot act out of mere kindness in allowing patients an extra day or two in hospital from which they might benefit but which are not strictly necessary from the medical point of view. Kindness to one person in this respect would be cruelty towards another who was waiting for the bed.

It is not uncommon, indeed, to see a patient in a ward waiting, like a reproach, for the previous occupant of his bed to pack his things and leave. Doctors thus have to be like Pharaoh, and harden their hearts against the piteous pleas of their patients and their patients’ relatives.

It is hardly surprising in the circumstances that doctors become ratty, bad-tempered and unsympathetic. They are the ones who have to deal with the practical consequences of decisions to reduce the numbers of beds over which they had no control. In psychiatry, conditions are worse still: many hospitals operate on a 130 per cent bed occupancy rate (that is to say, a patient has only to go on leave from the hospital for a day for his bed to be occupied by someone else), and sometimes there is no bed available within a radius of 100 miles of a presenting patient.

Needless to say, this constant bed crisis – exacerbated but not caused by minor epidemics – is taken by managers as a sign of extreme efficiency. There is no fat in the NHS, only lean.

But the same could be said if there were only one bed available in the whole service: for it would certainly be occupied all the time. What admirable leanness, what admirable efficiency! The only possible improvement in efficiency would be to get rid of that one remaining bed: then we would have reached the acme of health management – that is to say, hospitals without any patients whatever.

It seems to have occurred to no one that hospitals should not be run like airlines, whose object is to keep their aeroplanes in the sky, completely filled with passengers, 24 hours a day. It is true that viewed from a certain angle empty hospital beds represent underused capacity and therefore inefficiency. But – quite apart from humanitarian considerations – repeatedly sending patients home from hospital before they can have their treatment is not exactly a triumph of rational organisation either. Goodness knows what economic loss, let alone human suffering, it causes.

So the argument over the existence or otherwise of the flu epidemic is almost a pleasant little scholastic diversion from one of the real problems facing the NHS. Bed shortages embitter patients and staff alike; they cause suffering and cruelty; and they are now chronic.

If you doubt what I say, try being ill after the epidemic or non-epidemic is over, and see how long it takes them to find you a bed.

The author is a hospital and prison doctor