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Reconstruction

THE RIGHT PATIENT IN THE RIGHT BED

FROM A CORRESPONDENT

Now that the cost of maintaining a patient in an acutehospital is so high, people are beginning to wonder, andnot for the first time, whether we should not economiseby providing other accommodation for some patients.Should not postoperative or convalescent cases, for

example, and the borderline chronic, be passed on to lessexpensive accommodation so that the beds they occupycan be set free for others ? ’?There is, of course, much to be said for the doctrine

the right patient in the right bed " if it is applied withintelligence. The need to secure better classification of

patients, so that only those who really require the

exceptional facilities of expensive diagnostic or thera-peutic units are drafted into them is widely recognised,and this approach underlies much of the reorganisationnow being carried through by the hospital managementcommittees with their different categories of bed, andby the regional hospital boards as they work towardsthe organisation of specialist centres. More can certainlybe done in this direction, notably by the provision ofhomes for the aged sick and for other patients forwhom hospital treatment is not strictly necessary at all.Obviously it is highly uneconomic to allow such

patients to occupy beds which are needed for hospitalpurposes.But how far can the principle be taken ? It is easy to

carry the argument so far as to make nonsense of it.Whenever the search for economies is being pressedspecially hard, as it is today, there are to be foundadvocates of a more extensive provision of the cheapercategories of recovery or convalescent beds. They relyon variants of an argument which runs like this : " Inthe large general hospital the bed costs E20 per week ;now we espy there patients-postoperative or convales-cent, let us say-who could be adequately accommodatedfor f5 a week in a separate home or hostel. Ergo, let usprovide such hostels and thereby save some E15 perweek." Thus, to quote a classical instance, Lord Cave’scommittee in 1921 suggested " the cost of new accommo-dation might be substantially reduced if the main

buildings could be restricted to the accommodation ofcases requiring constant medical or surgical supervision,and the less serious cases were removed to an auxiliaryhospital on the outskirts of the city," which would be"less expensive to build and maintain," while recupera-tion would be " pleasanter and more rapid."

AN ECONOMIC FALLACY

This argument, in one form or another, is continuallycropping up, but it is largely fallacious. For consider.In the large multi-purpose general hospital patients costvarying amounts-in some departments more, in othersless-and the so-called cost per patient per week is anabstract calculation, a mere average figure. It is quiteunscientific to pick out particular groups of patients, orpatients at particular periods of their stay, and assumethat after making other provision for them and replacingthem with other patients the average cost for the wholehospital would remain unaltered. The cost of E20 is onlywhat it is by reason of the presence of these -5-a-weekpatients. True there may be some overheads which wouldnot increase ; but to bring this factor into the picture is toplunge into complicated calculations, and the end-resultcould only be determined by a costing system as elaborateas that which guides Lord N uffield in distributing workamong his factories.The supposed saving will in fact be achieved only if a

number of somewhat unlikely conditions are fulfilled. If,

for example, the expensive diagnostic and therapeuticservices are working below capacity, because the numberof beds allocated to these departments is inadequate, itmay be possible to increase their load without propor-tionate additional cost. But this amounts to a freshproposition, involving the replanning of the whole serviceand a fresh calculation of costs. There will be no savingunless there are corresponding reductions in expensivefacilities elsewhere. The point was put in a King’sFund report of 1928 in a discussion on recoveryhomes :

" The addition of a recovery branch concentrates in the

parent hospital a larger number of patients who needexpensive methods of diagnosis, operations, and otherearly stages of treatment, and thus enables fuller use to bemade of the highly specialised staff and apparatus, therebyreducing cost and increasing efficiency of service. But thisresult is only produced if the staff and apparatus are notalready fully employed, and in that case would be producedby the addition of beds on the hospital site."

On the whole it was felt that the advantage of the

system, apart from any effect on cost of site or building,lay not in any reduction of maintenance costs, but inthe benefit to the patients of being in the country.

SOME PRACTICAL DISADVANTAGES

To reserve all the beds for acute cases would also haveserious disadvantages for the nursing staff. The work ofa ward would become so heavy that more nurses wouldhave to be provided and costs would increase. To followa case through is an important part of nurses’ training,and even if the student nurses were seconded to the

recovery home they would not see the same patients allthrough their illness. If it should not be possible tosecond the student nurses to the recovery home there isthe added disadvantage that they will have no experienceof the convalescent patient. On the other hand, it ismore difficult to get good trained staff for a recoveryhome, because the work is less interesting from a nursingpoint of view. At the same time the trained staff at themain hospital are probably finding the work too heavyand breaking down under the strain.

If the recovery home is any distance from the main

hospital it will be difficult to get the medical staff topay regular visits. It will also be difficult to attract

junior resident staff because of the less interesting work.Most patients are probably quite happy once they aresettled in the recovery home, but there is no doubt thatthey hate the idea of the move.The subject clearly needs more thought than it has

hitherto received. The hospital, it must be recognised, isbuilt up of departments whose cost varies considerably,and in fitting the departments together many compli-cated considerations come into play. Proper costingcertainly does not rule out as uneconomic the inclusionof departments providing simple and relatively inexpen-sive treatments in buildings which can, and do, also

provide the more expensive. What is needed is a depart-mental analysis of expenditure. When once we have it,and have accustomed ourselves to thinking in terms ofdepartmental costs rather than in those of the obsoleteaverage cost per bed, many of the absurdities for whichmisuse of the latter is responsible’will dissolve.As opinion stands today it would seem astonishing to

many if it turned out to be more economic to nurse thechronic sick in units deliberately provided for themwithin the walls of the large general or teaching hospitalsthan in the simplest hostel that had to meet all its ownoverheads. Impossible? ‘- A little thought will soonconvince the sceptical that they have been making allsorts of assumptions for which there is no basis. The"

average cost per bed " is a plausible basis for notions- about keeping expensive hospitals for expensive patients.But it is a highly unreliable one.