Bed occupancy 1: Why does it matter?

Introduction

This is part one of a series of blogs on bed occupancy in General Adult Psychiatry (GAP) in Scotland. In order to make sense of the findings of a Freedom of Information (Scotland) Act (FOISA) request to all NHS Boards, some background is probably necessary.

There are four parts:

1. An overview of bed occupancy in psychiatry, what we know about it, and why it's important.
2. The factors affecting bed occupancy.
3. Reporting of bed occupancy.
4. Bed occupancy in GAP in Scotland 2018-2023 - findings from a Freedom of Information request.

Why is bed occupancy an issue?

A colleague recently posted on twitter that there were no more psychiatric beds available in Scotland. For anyone who has been on-call for psychiatry in the last few years, this has seemed like an occasional occurrence. In the last year or two it does seem to be becoming more common although it is not clear if it is truly a lack of beds or whether the 'availability' of beds is dependent on who is asking.

For example, if you are an NHS Board that is usually running at over 100% occupancy, you are unlikely to be able to have beds in 24-48 hours, neighbouring NHS Boards will know this, and they may therefore assume that any patient you admit to them will not be transferred back quickly. All NHS Boards will usually keep the last 1-2 beds for their patients and they are reluctant to give up their last remaining beds when they may not get that bed back quickly.

The lack of beds has impacts for all parties involved.

For patients, it means that you might not get a local psychiatric bed and you may need to be transferred to another NHS Board. This is stressful, takes time, and you will receive care from a team and a service that you probably don't know. Your admission is likely to be longer because it is slower to deliver care when you don't have access to notes or those already involved with the patient.

For relatives, it means that your loved one may be admitted to another NHS Board area. There may not be public transport and if you have a car, you may need to spend time driving to visit your relative. This is an 'Out of Area Placement' (OAP) and the Nuffield Trust have recently published updated data on OAPs.

For staff, it means that you have to phone around neighbouring NHS Boards trying to find a bed. Often, they will tell you that they don't have a bed and you'll have to convince them that admission is the only option available to you. Usually, a consultant-to-consultant phone call is expected which means that  if the transfer if 'out-of-hours', two senior psychiatrists need to be woken up to have a discussion about a patient that neither has seen or probably will see. Meanwhile, the patient is sitting without a bed and waiting for transport.

Systems under stress

Although this series of blog posts relates primarily to bed availability, the number of available beds is a function of how well all the other parts of the system are working. For example, the Nuffield Trust have recognised that out-of-area placements arise due to a whole system under stress, saying:

"OAPs are an indicator of a whole mental health system under pressure, not simply the result of too few acute mental health beds. A lack of focus on prevention, high levels of delayed discharges, increasing pressures in community care, lack of crisis response, and a rise in Mental Health Act use can all increase the pressure on bed capacity, which can in turn lead to reliance on OAPs." (Nuffield Trust, 2022)

If your CMHTs are struggling, they are less able to take over the care of patients being discharged from hospital - this prolongs the length of stay. CMHTs may lack the staff to deliver more intensive care to patients who are becoming unwell, and the threshold for admission may reduce. Crisis Teams may be under-staffed and they may be unable to provide intensive home treatment to lots of patients. If you have high levels of locums (many of which may not be as experienced as a 'substantive' consultant psychiatrist) care may take longer to deliver.

Ultimately, all roads lead to the inpatient bed. It is the 'final common pathway' for a complex system of care that has been pushed to the limit and beyond it.

What is bed occupancy?

Put simply, bed occupancy is the proportion (expressed as a percentage) of your beds that are occupied at any given time (usually counted at midnight) by a patient. If you have twenty beds and you have admitted ten patients, you are 50% full. If you have admitted twenty patients, you are 100% full.

More on how bed occupancy is calculated and reported is in part 2 of this series.

Optimum bed occupancy

There is a general acceptance that the 'optimum' (or ideal) bed occupancy is 85%. The assumption is that this means that you are using your expensive inpatient beds most efficiently, with a low risk of overload/ failure, and that you also have some 'give' in the system for periods of higher demand.

This figure of 85% is widely used as a reasonable 'target' and has been for some considerable time. For example, the Royal College of Psychiatrists (RCPsych) stated in 1998 that:

"Bed occupancy should not exceed 85%, if a safe environment is to be provided. Higher rates of occupancy also lead to pressure for premature discharge, leading to disturbed behaviour in the community and early relapse." (RCPsych, 1998)

This College report is no longer available but in 2011 they continued to indicate that an occupancy figure of 85% or less was a marker of a 'good ward' (RCPsych, 2011). The RCPsych continues to argue that there should be a maximum bed occupancy of 85%.

NHS Providers also refers to an 85% target when reporting bed occupancy for the NHS in general. The British Medical Association (BMA) also use an 85% figure when reporting occupancy published by NHS England.

Problems with a 85% target

One problem with this 85% figure is that it doesn't automatically match the reality of health care and it doesn't guarantee that your load is being matched to need or that your care is safe and/ or effective. You can have unsafe care with low occupancy and safe care with high occupancy. It's arguably a proxy measure rather than a direct measure of good care and functioning systems.

It's not hard to recognise that you can struggle to provide good care with low occupancy (if you lack staff and/or if your patients are very unwell, for example) and in other cases you can cope with higher occupancy without being over-loaded (if most of your patients are simply waiting for discharge, for example).

A more detailed critique of this 85% figure and of the balance between optimised care and system load can be found on this Improvement Science Blog.

The risks of over-occupancy

Risks to patient care

There is extensive evidence that increased occupancy is associated with adverse outcomes. A study in 2011 reported that the loss of beds over time correlated with an increased risk of involuntary admissions (Keown, 2011). Further, there have also been numerous studies that have found consistent associations between over-occupancy and risk of violence and aggression in psychiatric wards (Palmstierna, 1991; El-Gilany, 2010; Grassi, 2006; Ng, 2001; Nijman, 1999; Palmstierna, 1995; Virtanen, 2011).

Risks to staff

It was always the case that there would be peaks of high occupancy but that after a week or two they would reduce and staff would have time to 'recover'. Over the last few years (and with the added impacts of the COVID-19 pandemic) it seems likely that constant high occupancy is taking its toll on staff. This occurs via the direct effects of high workload, but also due to the increased risks of adverse events and violence that occurs with over-occupancy.

When systems are under pressure it is always supervision, training, and recovery time (due to having to cover extra shifts) that are sacrificed first.

There is, therefore, compelling evidence that whatever the ideal occupancy level, if it's too high then there are negative effects on staff (stress and burnout) and patient outcomes (increased adverse events, typically aggression).

Managing bed occupancy (and pass beds)

Many people might think it's odd to have more patients than actual beds, but it is relatively common during periods of high demand. Whilst it's hard to admit more than one patient to a bed in other specialties, in psychiatry it is quite common.

Pass beds

Since it's routine for many patients to have passes as they approach discharge (particularly with longer admissions), there will be periods when their physical bed on the ward does not have someone in it. This is a 'pass bed' and it is frequently used to admit someone else in the short-term.

The hope/ plan is that you can then find another bed (or discharge the new patient) before the old one comes back. During this time, you will have a bed occupancy of over 100%. If you have twenty beds, all of which are full, but two patients out on pass, and two patients admitted to those pass beds, then your occupancy will be 110% (22/10 = 1.1 = 110%).

Problems arise if your old patient is not well enough to be discharged, or your new patient cannot be discharged quickly. You have essentially double-booked the bed. Although people will argue that they have an 'exit strategy' for double-booking the bed, often it doesn't work out that way and staff can spend hours juggling patients around.

Surge beds

At least one NHS Board has started using alternatives to actual beds in actual bedrooms. For example, NHS Tayside has been using 'surge' beds for some time. This means that there is a mattress in an emptied interview room that can be used to admit a patient, but that room does not have the same facilities as a standard bedroom. There is no en-suite bathroom, nowhere to store clothes or possessions, and it may not have the same safety features as a bona fide psychiatric bedroom.

It also means that if you are using your interview rooms as bedrooms, there are fewer rooms for staff to see patients. Routine activities take longer, and all aspects of patient care are affected.

The Mental Welfare Commission for Scotland (MWC) has acknowledged the use of these rooms and has commented:

"It offers very little space, comfort or privacy and no en-suite bathroom facilities. Apart from a single bed there is no other storage for a patient’s personal belongings. We raised our concerns about this policy and the compromises to patient care, treatment and dignity." (Mental Welfare Commission, 2022)

Why not just build more beds?

It may make sense to simply build more hospital beds. After all, this will give you the capacity you need won't it?

There are a number of issues, however:

1. Hospital beds are expensive. Most NHS Boards are struggling to fund existing services, let alone expand their current ones.
2. All beds have to be staffed. Even if you could build more beds you might not be able to find the staff to ensure that care is safe and effective. Nurses are leaving the profession (in all specialties) due to high stress and burnout. They are also realising that they can work with less stress and more money by being 'agency' nurses; often covering the gaps in the wards that they used to work in.

There is another good reason why building more beds doesn't always work: it's called Roemer's Law.

First proposed in 1959 (Shain, 1959) the principle states that: "in an insured population, a hospital bed built is a bed filled." Although there was some uncertainty about whether it only applied to specific situations (e.g. US-based healthcare), there is evidence that Roemer's Law appears robust (Delamater, 2013; Ginsburg, 1983; Phillip, 1984; Rohrer, 1990).

This means that you can't just build your way out of increased bed occupancy since your beds will almost certainly always be full however many you have. The second part of this series will look at the factors affecting bed occupancy and what options are available to address this issue.

References

Delamater, P. L., Messina, J. P., Grady, S. C., et al (2013) Do More Hospital Beds Lead to Higher Hospitalization Rates? A Spatial Examination of Roemer’s Law. PLoS One, 8, e54900. https://doi.org/10.1371/journal.pone.0054900

El-Gilany, A. H., El-Wehady, A. & Amr, M. (2010) Violence Against Primary Health Care Workers in Al-Hassa, Saudi Arabia. Journal of Interpersonal Violence, 25, 716-734. http://dx.doi.org/10.1177/0886260509334395

Ginsburg, P. B. & Koretz, D. M. (1983) Bed Availability and Hospital Utilization: Estimates of the "Roemer Effect". Health Care Financing Review, 5, 87-92. https://www.ncbi.nlm.nih.gov/pubmed/10310279

Grassi, L., Biancosino, B., Marmai, L., et al (2006) Violence in psychiatric units: a 7-year Italian study of persistently assaultive patients. Social Psychiatry and Psychiatric Epidemiology, 41, 698-703. http://dx.doi.org/10.1007/s00127-006-0088-5

Keown, P., Weich, S., Bhui, K. S., et al (2011) Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study. BMJ, 343, d3736. http://dx.doi.org/10.1136/bmj.d3736

Mental Welfare Commission for Scotland (2022) Report on announced visit to: Ward 2, Carseview Centre, 4 Tom Macdonald Avenue, Dundee DD2 1NH. Date of Visit: 29 November 2021. Edinburgh: Mental Welfare Commission for Scotland. https://www.mwcscot.org.uk/sites/default/files/2022-03/Carseview-Ward2-20211129-a.pdf

Ng, B., Kumar, S., Ranclaud, M., et al (2001) Ward Crowding and Incidents of Violence on an Acute Psychiatric Inpatient Unit. Psychiatric Services, 52, 521-525. http://ps.psychiatryonline.org/cgi/content/abstract/52/4/521 

Nijman, H. L. I. & Rector, G. (1999) Crowding and Aggression on Inpatient Psychiatric Wards. Psychiatric Services, 50, 830-831. http://ps.psychiatryonline.org/cgi/content/abstract/50/6/830 

Palmstierna, T. & Wistedt, B. (1995) Changes in the pattern of aggressive behaviour among inpatients with changed ward organization. Acta Psychiatrica Scandinavica, 91, 32-35. http://dx.doi.org/10.1111/j.1600-0447.1995.tb09738.x

Palmstierna, T., Huitfeldt, B. & Wistedt, B. (1991) The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit. Hospital & Community Psychiatry, 42, 1237-1240. http://dx.doi.org/10.1176/ps.42.12.1237

Phillip, P. J., Mullner, R. & Andes, S. (1984) Toward a better understanding of hospital occupancy rates. Health Care Financing Review, 5, 53-61. https://www.ncbi.nlm.nih.gov/pubmed/10310946

Rohrer, J. E. (1990) Supply-Induced Demand for Hospital Care. Health Services Management Research, 3, 41-48. https://doi.org/10.1177/095148489000300105

Royal College of Psychiatrists (1998) CR62. 'Not just Bricks and Mortar'. Report of the Working Group on the size, staffing, structure, siting and security of new acute adult psychiatric in-patient units. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/publications/collegereports/cr/cr62.aspx [NO LONGER AVAILABLE]

Royal College of Psychiatrists (2011) OP79. Do the right thing: how to judge a good ward. Ten standards for adult in-patient mental healthcare. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/op/op79.aspx [NO LONGER AVAILABLE]

Shain, M. & Roemer, M. I. (1959) Hospital costs relate to the supply of beds. Modern Hospital, 92, 71-73. https://www.ncbi.nlm.nih.gov/pubmed/13644010

Virtanen, M., Vahtera, J., Batty, G. D., et al (2011) Overcrowding in psychiatric wards and physical assaults on staff: data-linked longitudinal study. British Journal of Psychiatry, 198, 149-155. http://dx.doi.org/10.1192/bjp.bp.110.082388