Don’t count the beds

The fight to defend health services is never more intense than when beds are at stake. The current struggle over the future of London’s major hospitals is a clear example, and even a cursory glance at the defensive campaigns of the 1970s and 1980s throws up numerous other causes célèbres: witness Bethnal Green, Hounslow, the Elizabeth Garrett Anderson and others.

Almost every town and city in the kingdom has, at one time or another, boasted its own ‘Save Our Hospital’ campaign, as the public has rallied to the cause of defending hospital beds. Yet despite such activity, the number of acute hospital beds in England fell from 158,000 in 1974 to 123,000 in 1989.

The recent Audit Commission report Lying in wait raised the stakes once more, proposing that 27,000 acute beds could be closed without detriment to the service, provided the remaining beds were used more efficiently. Needless to say, this suggestion met with a howl of protest from almost every quarter.

In all of this, the acute hospital bed emerges as a central focus for political conflict over health care, in a way in which, for example, the number of health visitors in a locality, or the waiting time for hearing aids have never done. But why such fierce combat over hospital beds, which we all would hope never to occupy? The answer lies not in the bed itself, but in what it stands for.

To the health service manager, the bed represents an index of resource use, a measure by which performance — in terms of throughput, occupancy rates, value for money — will be assessed. A bed has to be staffed, and drains the budget.

To the community, by contrast, the bed is a powerful metaphor for the human, altruistic, caring values which the NHS embodies. A bed is a place to be cared for, to recover, be healed, even to make one’s home. A place to lie, perhaps a place to die. It seems, however inadequately, to be the tangible expression for all that is best and most admirable about our health service.

And to those who, over many years, have fought to defend jobs and services, to strengthen the NHS and to make it more responsive to its users, the every bed saved is a trophy celebrating those glorious local battles won against the cuts — if only to be later lost.

This is precisely the problem. The hospital bed, the scarred battleground of struggles past, has outlived its relevance as a metaphor for the future. The changing face of primary and community care, the development of new drugs and medical technologies and the increasing importance of chronic and degenerative diseases, mean that the number of hospital beds available cannot be a useful measure of the quality or quantity of health care.

In reality, of course, the number of hospital beds has never been a valid index of the community’s access to care. Instead, to the professions, it has reflected the power of individual consultants over NHS resources.

The future of health care will not be dominated by the hospital, nor by the medical profession, nor by the acute hospital bed. It is long overdue that the metaphors surrounding the hospital bed be dropped, so that it can be seen clearly for what it is: just one component of health services, relevant only to those who need acute hospital care