RECENT coverage of the pressures, compounded by the COVID-19 pandemic and healthcare worker shortages, on public hospitals and the provision of acute care across Australia has underscored just how critical Australia’s acute care system really is vulnerable (here, here).
As hospitals represent the face of the modern healthcare system and cost the most in terms of healthcare expenditure, their problems are highlighted more than other parts of the healthcare system (here, here). In these times when hospital overcrowding and pressures on clinical staff are under intense scrutiny, an oft-repeated request from various stakeholders to address these issues is for more hospital beds (here , here, here).
Governments, in response, announce the allocation of more beds or even new hospitals (here, here, here). However, are more hospital beds and more hospitals the solution to the acute care crisis? Would providing more hospital beds lead to sustainable solutions and align the Australian healthcare system with the practice of medicine in the 21st century?
Hospitals and hospital beds
In Australia, hospitals are an essential component of the healthcare system and form the foundation of the acute care system. Hospitals offer admitted and non-admitted services in public and private hospitals. Although public hospitals are owned and operated by state and territory governments, with partial funding from the Australian government, private hospitals are owned and operated by private organizations and subsidized through the private health insurance model.
In 2020-2021 there were 697 public hospitals in Australia and according to the most recent data (2016-2017) there were 657 private hospitals in Australia. In 2019-20, public hospital recurrent spending was $66.4 billion, with state and territory governments and the Australian government contributing funding (here, here). Spending continues to grow with per capita spending, increasing an average of 1.1% per year between 2014-15 and 2019-20.
In recent times, state and territory governments have lobbied the Australian government to increase its share of funding, as demand for acute care, labor costs and pressures on public hospitals mount. .
The oft-repeated request in the funding appeal is for additional hospital beds in public hospitals to meet the growing demand for acute care from the community.
So what are these hospital beds? Are they just furniture?
The Australian Institute of Health and Welfare defines an available hospital bed as “a suitably located and equipped chair-bed, trolley or crib where the necessary financial and human resources are provided for the care to admitted patients. There are alternative terms to “available beds”, including “active beds” and “basic beds”, among others.
The number of hospital beds available per 1000 people in Australia in 2016 was 3.8. This represents a sharp decrease from the year 2000 when there were 76.9 beds per 1000 people.
Although this decrease may seem alarming, this trend reflects a decrease in the availability of beds in almost all developed countries. Health technology, changing models of inpatient care, and improved community services have all played a role in the decline in available beds. The trend in renewed calls for more hospital beds is disconcerting, but is there cause for concern? Do we need more hospitals and hospital beds?
less is more
Hospital overcrowding and the perception that this is caused by an insufficient number of inpatient beds often leads to a demand for more inpatient beds by the community and clinicians (here, here, here). However, the reality of establishing a bed is complex, with the requirement to consider the labor required to support bed-related care (here, here here). Moreover, the number of beds in a hospital is not a measure of success but simply an indicator of capacity. While adding beds increases the hospital’s ability to meet demand, it also increases running costs.
In an environment of budgetary constraints, it is relevant to ask whether the costs of hosting a bed are sustainable and whether the diversion of costs to the acute care system will lead to a lack of funding for other parts of the health care system.
No wonder the international trend in developed countries has seen a decrease in the total number of hospital beds.
Changing models of care and health technologies, such as telehealth and virtual health care, have shifted aspects of hospital care to the community, reducing the requirement for patients to stay longer long as needed in hospitals.
The COVID-19 pandemic has taught us clearly that healthcare systems are made up of many interconnected points of care and that hospitals do not operate in isolation. Therefore, a one-dimensional approach of increasing hospital beds or building new hospitals to alleviate community health care demand is an inefficient and unsustainable approach (here, here, here). A multi-pronged approach with initiatives inside and outside of hospitals is needed to improve capacity to meet growing community health care demands.
Undoubtedly, one of the main factors of emergency department overcrowding and blocked access is the hospital’s insufficient capacity to admit patients. However, the first order solution is not always to increase the number of hospital beds. This would look at internal operational processes at the hospital, such as discharge processes (here, here).
By streamlining and expediting the discharge of inpatients, considerable capacity can be added to the hospital. As a rule, far fewer patients are discharged on weekends and many patients do not need to be treated in hospital. By looking at these factors and freeing up patients who can be cared for at home or in a subacute or community setting, bed space can be added to the hospital. Additionally, unused specialty beds can be converted for general or multipurpose use, further increasing the hospital’s capacity. Additionally, same-day discharge policies can be tailored to specific surgical procedures.
There are convincing evidence that well-monitored home care can be safer and more effective for eligible patients, including those at risk of hospital-acquired infections. Outside the hospital, programs such as “Hospital in the Home” (HITH), which allow patients to receive hospital-level care in their homes or similar settings, have helped reduce the pressure on hospitals. and free up much-needed beds. In Victoria, 49 HIVD sites and approximately 6% of all bed days are provided under this program. Recent research has indicated that HIVI patients were less likely to be readmitted and have lower mortality rates than hospitalized patients. SHAD care can be extended to many clinical areas.
In a broader political context, the demand for hospital beds can be reduced by improving the health of the population. This can be achieved in the short term by preventing admissions and facilitating early discharge (here, here). Inappropriate emergency admissions can be avoided through medical observation units to direct patients to more appropriate environments, and elective admissions can be avoided by transferring diagnoses from inpatients to outpatients. To enable early discharge, alternatives to hospital care, including nursing homes and subacute care, need to be developed.
In the longer term, upstream investments in preventive health programs will reduce the burden of disease in the population and therefore require acute care. Additionally, the more efficient management of many patients with chronic and complex conditions in primary care, aided by a revised funding model to proactively manage care, will help to significantly reduce the demand for additional hospital beds.
Reducing the demand on hospitals and finding solutions to the current pressures on the acute care system is, admittedly, a complex process. However, to ease the pressure on hospitals, reliance on unsustainable and inefficient options, such as adding hospital beds, must be challenged.
With programs such as STID and emerging health technologies, some aspects of acute care currently provided may be provided outside of hospitals. In addition, better demand management and streamlining of discharge processes ensuring efficient use of hospital space can increase hospital capacity without requiring additional hospital beds. Therefore, these measures should be carefully considered before adding more beds to the acute care system.
Associate Professor Sandeep Reddy is the MBA (Healthcare Management) Program Director at Deakin University. In addition to a medical degree, he has qualifications in medical informatics, management and public health. He has managed various health service projects and formulated high-level policies in Australia, New Zealand and Europe.
Professor Grant Phelps is a gastroenterologist and critical care physician in public and private practice in the Victoria region. He is a professor at Deakin’s Medical School where he taught in the MBA program. He is Chairman and President of Hepatitis Australia.
Affiliate Associate Professor John Rasa is Director of the Health Care Financing Unit at Deakin University School of Health.
Statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, MJA or InSight+, unless otherwise stated.
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