A ‘bed blocking’ crisis threatens the NHS. Here’s how to fix it

The NHS is the victim of its own success. Every patient whose life it saves and patches up is a guaranteed re-attender. Currently, acute hospitals throughout the land are being prevented from performing their vital functions because their beds are filled by almost well people who are not quite able to return to their own homes. This may be because they have mobility needs, or are unable to fully self care, or sadly they may lack somebody to look after them.

These poor souls have rather rudely been awarded the sobriquet ‘bed blockers’.

As a consequence of this log-jamming, extremely unwell, unconscious, breathless and septic newly arriving patients are having to wait in ambulances because there simply is no room at the inn. Elective surgery is being cancelled for the same reason. The tremendous waste of resources and the expense of providing fully staffed hospitals that cannot admit patients is as mind-boggling as it is depressing.

Care in the community was suggested as a solution to the bed-blocking problem, but in reality it is an expensive fantasy. Where I live, it takes all night for two nurses to travel from one end of the county to the other, twice. Geography matters! In cities with hospitals at every corner and short distances involved, then maybe, just maybe, it can work.

Staff matter, too. If you make a health service career too academically challenging, you will persuade the more caring but less book-talented people to look elsewhere for work. The best nurses I have ever worked with all possessed tremendous humble ordinary sense and they also lacked any spirit of egotistic entitlement. They just loved to nurse.

Every nursing student nowadays must attain a degree qualification and be continuously appraised. I witness many worthy lasses and lads who work as healthcare assistants and domestics being turned away from nursing because they lack mere qualifications while excelling in caring human qualities, great presence of mind and naturally high esprit de corps.

The cure for the NHS is not simply to close beds in the hope of saving some dosh. It is to open low dependency hostels, where those nearly well ‘bed blockers’ can be housed while they await their return to their homes. This will free up acute hospital beds for the care of the acutely unwell, allow for elective surgery to resume, and provide for the optimal 85 to 90 per cent occupancy of acute beds which is necessary for safe surge management and for hygiene and infection control to be implemented.

The government should act urgently to provide these hostels. If the Jehovah’s Witnesses and McDonald’s Corporation can erect premises in a day, then perhaps Her Majesty’s Government has a chance of doing similarly in less than a decade.

Green-field, single storey, low dependency hostels are needed, with lots of parking for visitors and staff. Minimal medical cover could be provided by GPs. Physios, occupational therapists and social workers would do the bulk of the rehabilitation needed for the patients to get home. Basic care would be provided by health care assistants and the domestic staff, while needing little senior nursing supervision.

Why not provide some palliative care beds within the new build too? It is scandalous that terminally ill people are languishing in noisy acute wards with limited visitation by their kin. Move them out to the poppy field-hospital, and improve the quality of their dying.

If you think I am reinventing the wheel, then I confess I am a bit. All of the above was provided by ‘cottage hospitals’ until some well meaning, cost-cutting brainiacs decided to close them all and provide care in the community instead. This might have seemed like a nice idea, but the logistics never adequately materialised as it relied on local government supplying their end of the bargain, and they couldn’t.

The NHS has to meet the tsunami of unwell people coming into it in a humane manner. That is, without euthanasia, or rationing. To do this, it needs to realistically manage the ‘bed blockers’ within itself.

Quite honestly, when you and I become a bit helpless in our declining years, we won’t be asking for high tech medical miracles to be performed upon us, but only, appetite permitting, to be fed at the top end, and wiped clean at the other, and to be got home ASAP. Who needs a carer with a university degree to provide such basic needs? This kind of looking after is basic humanity learned during child rearing. I live in hopeful expectation that such a staple will still exist in a few years when you and I might need it.

Health service policy isn’t rocket science, or even brain surgery. It is simply giving a damn about the sick, who are with us always, even to the end of time.

  • Common sense article.
    Unfortunately, the Unions, the vested interests (Royal Colleges) will never allow it.
    They prefer to strike regarding overtime and weekend rates of pay.

  • frank davidson

    The article promotes thought. In 2010 I had a hip replacement and was ready to go home on the Thursday. Having had a lecture at the hospital before surgery I had made arrangements for a high toilet seat, special sleeping and toilet arrangements. I was ready to go. No, my arrangements must be inspected so I was patient until the following Tuesday and discharged myself. On the Wednesday someone from Welfare appeared and said all was well apart from my Lavatory arrangements. Apparently my raised toilet seat may not be strong enough. As a structural engineer I assured the lady that it was and stated I had made the wooden frame myself. Someone would be along. Indeed they were the district nurse arrived to remove my stitches followed a week later by an inspector for my lavatory. Too late I had removed the structure and was using the original. He said that was okay since it was up to me to use the original.

  • Dacorum

    We need to reinvent the Cottage hospital solution for the reasons you state.

    We also need to stop the reduction of hospital beds in acute hospitals.

    I fail to see the necessity of having of all nurses having a degree. That wasn’t necessary in the past. We used to have State Enrolled Nurses (bedside nurses) and State Registered Nurses (management nurses). We need to reintroduce the old system that would allow SENs to work their way up the nursing ladder if they wish to. That way we would get the best nurses who are both practical and qualified.

    The government has now withdrawn bursaries for nursing degrees from 2017 and students will now have to apply for loans and REPAY them, unlike their colleagues. It is a crazy policy. The government said this change would enable universities to offer up to 10,000 extra training places on pre-registration healthcare programmes. The reality however has been a 23% reduction in applications which any idiot in the government should have predicted! You really could not make it up. Doesn’t the government know anything about the basic economics that if you increase the price of obtaining a nursing degree, the demand from applicants would be bound to fall as alternative career options become more attractive?

    • Remember that it was LABOUR who brought about the ridiculous degreeification of nursing with all ts paperwork, form filling and bureaucracy.

      • Dacorum

        That may well be the case but this government has continued it.

        Would you not support the reintroduction of the old system of student nurses gaining basic experience first of care on the wards before having periods of paid study time to gain their qualifications interspersed with training on the job on wards so that by the time they pass their qualifications they are fully functional trained nurses without any student debt?

        The advantage of such a system would not only encourage many more good quality applicants to become nurses but also ensure that those who found the reality of nursing wasn’t for them would find out more quickly than those who nowadays immediately start studying for nursing degrees away from the wards and who will incur very significant amounts of student debts in the process.

        • Man_on_Richmond_Bridge

          Dacorum you speak common sense but there’s none of that about when a discussion on NHS training occurs.

          • Dacorum

            Thank you!

  • Bill Rogers

    Similarly, we should replace most GPs with frontline paramedics who are highly skilled in minor ailments and fast referral. They will be quicker to train, less expensive and more effective than GPs who are overtrained for the job.

  • Mongo

    no mention of that other big elephant in the room that’s causing massive increased demand on the NHS?

    • Hermine Funkington-Rumpelstilz

      Rising numbers of (white) poor OAPs?

    • Mary Ann

      Lets hope that all those pensioners don’t have to come back from the EU.

  • Simon

    No this doesn’t work. Placing people in Cottage hospitals or so-called step down facilities just creates a bottle neck somewhere else. This will not solve the problem of a fragmented system which keeps people from returning home.
    We have to make the person’s home a place where a higher level of care can take place. Most of us want to go back home and in many cases this should be possible if we can get the right support put in place. To do this requires integration of services wrapped around the patient with one person in charge. Sadly there are too many vested professional interests, regulators and restrictive practices involved to make this happen.

    • Dr Brian Campbell

      Hi Simon, I agree that in an ideal world, it would be best for people to go straight home from hospital, with all necessary care laid on there. However, we are nowhere near achieving that at this time. The NHS acute hospitals are at meltdown point right NOW. My suggestions are for an immediate remedy that may avert a very real disaster in the near future. It will buy time, at the very least.

      I totally agree that there are too many cooks at the moment, and they are spoiling the broth. Here is some of the text from my originally submitted copy, which was excised for reasons of space, and possibly good taste. You may or may not agree with my opinions therein:

      “In my thirty plus years in the health service, I have witnessed the burgeoning, oxygen consuming algal bloom of non health professionals interfering, micro-managing and demoralising the front line soldiers who fight for this nation’s health, though all with the best of intentions, I’m sure. Alas, with so many generals and so few foot-soldiers, I fear the mass assault by the sick will result in another Custer’s Last Stand. As a mere frontline warrior myself, I am getting heartily tired of giving of my best to a regime that frustrates me at every turn. You could call me a lion led by donkeys. When I signed up to this game, I believed professionals were raised to manage themselves and each other. If only we could be just allowed to get on with our vocation….

      The NHS does not need to be privatised, it simply needs to be properly provided for. The private sector might help out in a non-profit making way (for tax breaks perhaps?) I am no economist, so I don’t know. It has clearly been shown worldwide that if more than about £3500 is spent per capita per year on healthcare, then there is no further gain in life expectancy. The UK currently spends this much. More cash is not the answer. Greater value for money is. Privately run hostels, paid by HMG, could be incentivised by the number of patients they safely get home in the shortest time, and thus by their ability to accept new referrals from the acute hospitals.”

      • “Privately run hostels, paid by HMG, could be incentivised by the number of patients they safely get home in the shortest time, and thus by their ability to accept new referrals from the acute hospitals.”

        In practice, I see a serious flaw in this plan. Once a private company is incentivised in this manner, some bean counter will be discharging old ladies and gentlemen who are far from fit to manage themselves. This flaw might not prove immediately disastrous when the patient has someone at home who is fit enough and competent enough to manage their care, but most of the difficult cases concern people who have no one, or no one capable of looking after their needs.

        Why do these hostals need to be privately run anyway? At least if they were managed by people whose vocation is medicine rather than accountancy, we might have confidence that the decision to send the patient home was made on clinical rather than financial grounds.

        The ridiculous divide between what is called medical and what is called social care, needs to be scrapped. An eighty-five year old recovering from a broken hip is suffering from a medical condition until she is walking again, no matter whether she is in hospital or a care home. We have to fund both kinds of care. One way to find part of the money at least is to make sure that we charge the hotel costs of all our patients. There can be no justification for providing free food, bedding and other consumable costs that would fall on the patient were they at home. I know this would not generate a vast sum, but it would help spread the impact of medical spending.

        • Man_on_Richmond_Bridge

          Good points Arthur. The bean counters will ensure that they get the “right” company car for themselves instead of the quality of care the patients should receive.

  • themanwhocan

    I would add a shorter working week could help too.

  • Bill

    I sort of agree – up to a point
    My colleagues and myself did use to help run the sort of cottage hospital Brian is talking about here. We used to provide the ‘minimal’ medical cover. In the end though, we relinquished the contract, for a couple of reasons –
    Firstly, general practice became just too busy. The number of home visits gradually went up and up, due in no small measure to the multiple care homes that opened in our area. Generally, this was where patients were discharged to from the cottage hospital, but in many cases they were stable rather than relieved of their burden of multiple morbities, and required considerable medical input.
    Second, the demands on the ‘minimal’ medical cover also increased. Our local hospital had a big new PFI place built with less acute beds. Thus the pressure to transfer patients to our little hospital became more and more intense. Patients who were sicker and sicker were transferred and eventually demands were such that medical cover went from one doc every other day for 1/2 hour to 3 or 4 docs every day for over an hour. Our cottage hospital had no labs and no radiology and so there was a degree of seat-of-the pants flying when someone became worse, as they quite often did.
    In the end it just wasn’t safe, so we stopped doing it.

    • Dr Brian Campbell

      Believe me, we have faced all these issues too.

      The key is morale. Isolated units suffer lack of morale, and risk giving up the ghost. Every hospital is party to many others and must always actively feel part of that solidarity. This is the basic mechanism of society, let’s be honest.

      The regime wants hospitals to compete against one another, when what is needed is cooperation with one another. We all do the same job, after all.

      The other big consideration is the flow of power: from top-down or bottom-up? I favour the latter for the simple reason that people at the bottom have a more natural intuitive understanding of the issues of any business. They thus make the best leaders. Simples!

      • Man_on_Richmond_Bridge

        Egos will never allow the flow of power from the bottom – simples!!!
        Just not going to happen.

  • Flintshire Ian

    From where do you plan to magic up the necessary numbers of Physios, OTs and social workers?

    • Dr Brian Campbell

      From the same Fairy-Land where all NHS staff come from, is my answer. Is that sufficient for your query?

      • Flintshire Ian

        The NHS fairy needs some stronger spells. There probably are enough qualified OTs available since the cuts began to bite and people weren’t replaced if they left, but phyisios can have attractive careers in the private sector. Some physios in professional sport are on salary and benefits packages that would reduce a GP to tears of jealousy. There has been a recruitment and retention crisis in social work for years.

      • Mary Ann

        The EU?

    • Mary Ann

      You spend more money, an anathema to the Tories.

  • Mary Ann

    Weren’t Cottage hospitals used for low level nursing care years ago, and didn’t a lot of them get closed in the name of efficiency.