The real rationale for bed cuts? And where is the evidence?

Upgraded comment from Paul F to previous post:

“Behind these proposals is an organisation desperate to cut costs. The “Success” in the title of the “Success Regime” is success in cutting spending in Devon to meet the NHS budget – it is not about successful healthcare for people, it is all about saving money.

They talk about “efficiency savings” rather than “cost cutting” and the difference is vitally important. “Efficiency savings” are when you can provide the same level of care for less money by being more efficient, whilst “cost cutting” is when you reduce your costs by reducing the quality of care.

The underlying principle of their proposals is that home-based care is as good medically but can be provided at a fraction of the cost.

On top of the reduction in hospital beds that would result from home care, they claim that beds are already under-utilised and that even more beds can be cut if we can cut bed blocking (so that social care support is available for patients who need it so that they can leave hospital).

All these make sense if the evidence is there to back them up, but these claims need to be independently analysed and verified. Additionally there is the inevitable fight about where the cuts in beds will be made, and questions about whether the replacement home care and social services will be in place and fully ready before the cuts in beds are made.

Like Claire, I set out to see whether the written evidence actually supports these proposals or whether the evidence has been fudged.

The Home Care proposal is based on pilots already undertaken in North Devon – and on formal reports that have been written following these pilots. When reading analyses like these, I want to see them take the data, ideally using objective measures of health improvement (such as mobility resulting from physio on some standardised scale) though subjective surveys of patients also have a value, and then summarise the good and bad points and only then draw conclusions about whether the pilot should be extended to the whole of the CCG area.

Unfortunately the reports are lacking in objective medical assessments of home care vs. hospital care, relying almost exclusively on subjective patient surveys of home care and without comparative subjective patient surveys of hospital care.

Even more worrying is that the reports seem to have been written in the wrong direction, starting with an objective in mind (i.e. a decision to roll home care out across Devon) and then selecting data to support this case (i.e. they give lots of individual survey comments about how good home care is but gloss over the negative comments).

The analysis is also deficient in highlighting potential down-sides to their proposals (for example increased difficulties for patients and visitors who do need hospital care to travel to the now much more distant hospitals) or the risks that might be inherent in these changes of approach (i.e. availability of immediate help from hospital nurses cf. planned visits from home carers, ability to handle emergency complications that need hospital facilities which are not available when people are being treated at home).

The reports do not give proposals for improving availability for social care for people who should be leaving hospital, because that is not funded by the NHS and so outside their control, but nevertheless they are going to cut those beds.

I guess they see this as a one-off issue, because once they have implemented home care, the people won’t be blocking hospital beds because they won’t actually be in hospital. Of course, that doesn’t deal with either this one-off issue of people who are in the beds when they are cut, or the resulting long-term issue of people now being treated at home who start to need social care in the same way that they would if they had been in hospital – but their thinking is presumably that at least these people are not blocking their beds.

The bottom line on home care is that it may well be as good or even better (for certain types of patients and conditions) but the evidence is insufficient to show this, and there are no guidelines set to ensure that the new approach is only chosen for patients who will benefit and not be at risk from home care.

BUT, suppose we assume that there is solid evidence that home care really works – the next issue is where to cut these beds.

The issue with the CCG approach is that they are looking simply at financial numbers, and not at the impact it may have on the ability of patients or visitors to get too and from hospitals which may now by 30-50 miles further away.

For example, the beds in Ottery St Mary [Axminster] and Budleigh Salterton hospitals are already gone, the beds in Honiton hospital are going in every option currently put forward by the CCG, and yet one of the options proposed also eliminates the beds in Sidmouth hospital. That would mean that ALL the community beds in central East Devon will be gone. How can this be right?”

Finally, we also need to be careful about use of terminology – whether to call it “over spending” or “under funding”.

We need to be realistic that if we decided to treat every medical condition, however minor, using the best possible drugs, however expensive, NHS costs would probably be unaffordable.

The reality is that NHS care has to be prioritised, with some treatments rationed or unavailable. So the issue is whether this prioritisation is undertaken nationally to set the national budget with regions spending what is needed to achieve this standard of care, or whether you continue as at present and fund each region individually (with inevitable inequalities in funding because demographics e.g. an older than average population or population growth due to massive house building or new towns are not properly factored in) and allow them to do the best with the funds they are given, which inevitably results in variations of care which get called postcode lotteries – and these regional variations in medical care (postcode lotteries) are likely to increase when you use local “Success Regimes” to cut costs (oops sorry – make efficiency savings) in individual regions rather than deal with matching treatments to budget at a national level.

(Disclosure: I have been told by my own doctor, for instance, that I can’t have a treatment I might need because it is not available in Devon, but if I lived in Gloucestershire – the nearest available location – I could have it. Fortunately not life threatening – just somewhat detrimental to my quality of life.)