What are the lessons learnt by countries that have had dramatic reductions of their hospital bed capacity?

Summary

The issue

Counting beds is a rather poor way to measure the capacity of a modern health care system. This is especially the case given the unexpected difficulty of even defining a hospital bed, and in light of many alternatives to hospital care now available.

Many countries have decided to reduce the number of hospital beds. Some have succeeded by making a sustained investment in alternative facilities, but some have been so successful that they now face shortages, meaning growing waiting lists and difficulties in admitting acutely ill patients. Other countries have had more difficulty reducing the number of beds, especially where hospital ownership is dispersed among several organizations. Some central and eastern European countries have faced problems in trying to apply reforms without fully adjusting policies to their particular socioeconomic context, human resources and stakeholders.

Findings

There is some evidence that the need for hospital beds can be reduced by:

• coordinating disease management programs;
• directing patients to more appropriate facilities;
• shifting from inpatient to ambulatory interventions;
• facilitating earlier discharges.

However, there is also contradictory evidence suggesting that both reduced admissions and reduced lengths of stay may lead to increased cost per patient, and that many of the anticipated cost savings arising from bed closures may not be realized because of the cost of alternative modes of care. 

There is little empirical evidence concerning the overall implications of reduction in hospital beds. Most studies come from Canada and the United States, and to a lesser degree, the United Kingdom. The ability to draw lessons for all of Europe is therefore limited. The evidence largely examines impacts on staff, access to care, and terminal care.

There is extensive evidence that reductions in hospital capacity adversely affect the remaining staff – especially those transferred to other facilities – mainly because of poor communication and increased workload. However, there is some evidence that careful relocation of staff can lead to improved job satisfaction and decreased burnout.

Prediction of the impact of bed reductions on patients is critically dependent on the starting level, and specifically on the availability of spare capacity or alternative facilities. There is limited evidence that where there is spare capacity a relatively modest reduction in hospital beds may not adversely affect either quality of care or the health status of the population, and that it may have a minimal effect on access to care by elderly people.

In contrast, where capacity is already constrained, major bed reductions may substantially reduce the ability to admit acutely ill patients in emergencies. There is also limited evidence suggesting that a dramatic reduction in hospital beds will substantially reduce the length of stay for patients at the end of their life, thus significantly increasing the number of patients who die away from the hospital.

Policy considerations

Strategies to reduce hospital bed capacity should take into account the overall pattern of health and social services in the affected area and include:

• sustained investment in alternative facilities;
• carefully planned transfer of staff to other facilities; and
• mechanisms to reduce inappropriate admissions, and facilitate more rapid discharge.