Can good bed management solve the overcrowding in accident and emergency departments?

The NHS Plan 1 makes the commitments that a patient’s total time in accident and emergency (A&E) will be no more than four hours. Many trusts are currently struggling to reduce four hour trolley waits (the time from the decision to admit (DTA) to leaving A&E). A recent survey conducted by the BMA and the British Association for Accident and Emergency Medicine suggests that official figures give an over-optimistic picture of the current pressures in A&E departments, and long patient waits are still common. The ability to move patients with a DTA out of A&E depends on the ability of the hospital to accommodate them (or to accommodate patients from the MAU, etc, to make room available). This movement is normally the responsibility of the bed management (BM) function, according to the National Audit Office (NAO), and this is the case in all trusts with which we are familiar. BM forms an important part of operational capacity planning and control, a wider activity concerned with the efficient use of resources. Outside the health context, the production/operations function of an organisation is concerned with activities such as scheduling and work flow to enable throughput to meet demand, and minimise work in progress and maximise resource utilisation. Despite the obvious analogies, very few acute hospitals have an operations management function. The objective of this paper is to demonstrate the part that operational capacity planning and control, in particular BM, plays, and could play, in improving service delivery. It starts by describing the typical function and structure of BM in acute hospitals, patterns of hospital activity, and their effects, particularly on A&E. Developments in operational capacity planning are then considered. These aim to improve planning and management of supply and demand, and moving towards and maintaining lower bed occupancy in medicine. BM has a key part to play in these changes, which have the potential to transform acute hospitals into systems that can deliver the government’s emergency care commitments, including reducing the post-DTA wait component of A&E time. Recognising this, the Modernisation Agency is in the early stages of developing recommendations for good practice in BM, which will be evaluated at two trusts. The paper draws on data from a variety of studies and a range of projects, both complete and ongoing. Academics at the Manchester School of Management have undertaken two detailed surveys of BM practice for NW Region and the Greater Manchester Chief Executives Group, which included detailed interviews with BM staff and qualitative comparative analysis of the 12 acute hospitals in Greater Manchester, and study of the available literature on BM. We continue to have a close involvement through helping run a pilot training programme, involvement in the Greater Manchester Bed Managers’ Network, contributing to the Modernisation Agency’s BM good practice initiative, and pursuing ongoing academic research ideas. The quantitative analysis is derived from forecasting projects conducted for NW Region, a current project to support bed management with planning tools that are being developed and evaluated at a number of hospitals using action research methodologies, and a joint project with a Greater Manchester hospital to use operations management and operational research analysis techniques to improve capacity management. This paper starts by outlining the part BM plays in the flow of patients through acute inpatient beds, the context in which bed managers operate, and the impact this has on BM and the patient experience. Data from South Manchester University Hospitals NHS Trust (SMUHT), whose acute site is Wythenshawe Hospital, are used to illustrate the context and impact. The potential of BM to improved capacity planning in acute hospitals is then discussed, and several initiatives then described, drawing on experience in Greater Manchester and nationally.