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An exploratory study of bed management

Ruth Boaden, Nathan Proudlove and Melanie Wilson
Manchester School of Management, UMIST, Manchester, UK
Keywords Hospitals, Management, Information systems, United Kingdom Abstract This paper analyses the role of bed managers and the processes involved in admission, stay, transfer and discharge of patients in the hospital setting. The paper seeks to begin a discussion of the difficulties entailed in the allocation of beds within the context of confined resources. This is achieved by: a review of the somewhat sparse literature on bed management and associated issues; the development of frameworks of analysis with regard to what bed managers do and the information used to support the bed management function; and an explication of results from fieldwork. This is followed by a discussion of the scope of responsibility and career role of the bed manager as well as the potential and problems of bed data. Contacts with others investigating this field and other trusts indicate that the situation in Greater Manchester may be typical of most areas.

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Introduction and objectives Bed management The effective management of beds as a resource has always been an issue within the NHS (Green and Armstrong, 1994) but in the current climate of everincreasing demand for emergency beds and reducing acute capacity, there has been an increased focus on such activity. Despite this, the bed management process has received little attention in the academic literature and there are no national protocols for best practice in this area at present, apart from the 1992 Audit Commission Report Lying in Wait (Audit Commision, 1992). Other major national initiatives have addressed related aspects of resource management and service delivery and organisation, including the National Patients Access Team, the work of the Emergency Services Action Team (1998) and the current work being carried out by the National Audit Office in which data are being gathered from all acute trusts and will result in a report to Parliament in late 1999. This paper describes the results of a study conducted in 1998 into the role of hospital bed managers that formed part of an NHS-funded investigation into the provision of and support for bed management in Greater Manchester
We would like to express our thanks to all those who participated in the project. In particular, the help of Tracy Priest (Greater Manchester Ambulance Service) and Chris Brown (Greater Manchester Emergency Medical Admissions Policy Co-ordinator seconded to NW Region from the Department of Health) has been invaluable. The work was funded by the NHS Executive (North West) R&D Directorate. Many of the bed managers are subject to considerable day-to-day pressure and yet made time to talk about their role. For some, it seemed as if the process of answering the questions helped them to better understand their own role. Others were more confident about what they did and were able to provide perceptions of the role which have enhanced the results of this evaluation.

Journal of Management in Medicine, Vol. 13 No. 4, 1999, pp. 234-250. # MCB University Press, 0268-9235

(Boaden et al., 1998). Bed management is taken to consist of the tactical/ operational day-to-day allocation of beds and the strategic planning task of ensuring beds are available for (emergency) admissions whilst not restricting elective work by keeping beds idle (Brown, 1999). It is performed by nursing or managerial staff, some titled ``Bed Manager'', others not. This study considers their role on a trust-by-trust basis. The Birmingham and Solihull emergency admissions operational management system supplements such intra-hospital bed management with a central bed bureau (CBB) system overseen by an Emergency Capacity Manager. The CBB operates a quota system to spread emergency workload by (re)directing limited numbers of certain classes of patients, and monitor activity levels. The system covers six major secondary and tertiary care trusts within an eight-mile radius of Birmingham city centre (Healy, 1997; Elvin, 1999). Whilst there is potential for this type of inter-trust co-ordination of bed management in other areas, it is very uncommon. Factors in the success of the pan-Birmingham scheme include geographical proximity, good transport links and considerable commitment at Chief Executive level. It is also notable that the system has grown from the Birmingham bed bureau established in 1963 to assist GPs with arranging emergency admissions, suggesting an explicitly cooperative culture may have already been in place. In Greater Manchester, GMAS (the Greater Manchester Ambulance Service) have installed an information system which the bed managers use to inform each other of the general level of bed availability in their trusts, and the bed managers meet regularly to share experience and discuss initiatives. However, there seems no prospect of implementing an inter-trust bed management system along the lines of the pan-Birmingham approach. The aim of this paper is to contribute to an understanding of the process of bed management through an investigation of what bed managers do, based on experience of the situation in Greater Manchester. Contacts with others investigating the state of bed management, and with bed managers and senior managers from trusts in other areas, indicate that the findings reported here may be typical of most areas. The authors plan a more extensive study that would seek to confirm this. The authors' experience in Greater Manchester and elsewhere reveals that there is generally very little IT support for bed management. Data collection and use in bed management is considered in this paper, so the findings should also be of use to those involved in the design, development and implementation of bed management information systems. Structure of the paper Following a brief description of the methodology the rather sparse literature dealing with bed management is discussed. Theoretical frameworks concerning the context and scope of bed management and the information to support this function are then developed to begin to address the gap in the literature already mentioned. Results concerning the bed management process

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and role are presented and discussed, and suggestions for future work and possible paths for improvement are proposed. Methodology Information was gathered through a combination of analysis of documentation, desk-based research and semi-structured interviews with bed managers (or equivalent nominee) as subjects, in 14 hospital trusts in the Greater Manchester area. Questions focused on: the practice of bed management; the methods and problems of collecting bed data; the use, benefits and weakness of the bed management system; the adoption of various strategies to alleviate bed management pressures. Members of the research team also attended the regular bed managers' meetings to gather further information, listen to issues raised in a collective setting and clarify points arising from the reference material or interviews. A preliminary presentation of some of the findings was given at one of the bed managers' meetings and feedback incorporated. The process of bed management Bed management can be defined as:
... keeping a balance between flexibility for admitting emergency patients and high bed occupancy (which) has been an indicator of good hospital management since before the establishment of the NHS (Green and Armstrong, 1994, p. 20).

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The term itself may have developed in recent years, but the function has been carried out for much longer. Essentially, it concerns the placement of emergency admissions, but may extend to balancing of emergency and elective admissions since the two may require the same resources. Traditionally, a ``bed'' had been thought of as being something owned by a consultant and allocated by him/her as best thought fit. However, after a period of crisis when ``control by consultants broke down and staff were spending increasing time searching for beds and arguing about their relative rights to admit patients to them'' (Green and Armstrong, 1994, p. 20), many organisations have come to the view that beds should be seen as a resource owned by the organisation itself. Although there are some protagonists who believe that the bed is no longer an effective measure of capacity, and that finished consultant episodes (FCEs) or some other measure may be more appropriate, it seems that the bed is still seen by many as the main unit of currency for negotiation, and perhaps as a measure of power. There is relatively little literature on bed management as such compared to other topics such as the management of emergency admissions or the management of waiting lists. One of the few significant pieces of work in the area is Lying in Wait (Audit Commission, 1992). It uses as its basic framework the concept that bed management is influential at all stages of the process that a patient goes through (see Figure 1).

emergency admission placement elective admission stay discharge

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Figure 1. The process of bed management

bed availability and management

Source: Audit Commission, (1992)

This model does not necessarily imply that there is a single ``bed manager'' responsible for the whole of this process, but that there is a bed management process which interacts with each stage. Lying in Wait highlights three components of bed management: (1) Strategic decisions affecting the flow of patients. Ensuring that there are ``policies, procedures and standards agreed by the relevant parties for each stage of the flow of patients through the hospital'' (Audit Commission, 1992, p. 56). Such policies may be hospital-wide or localised, depending on the particular aspect of the process. (2) Day-to-day decisions. Made by ``individual doctors and nurses'' in line with agreed procedures. However, two other tasks with a management component are defined as the provision of a mechanism to match demand and supply ``usually an admissions or placement office where staff, supported by real-time information systems, deal with the allocation of both emergency and elective patients to wards'' (Audit Commission, 1992, p. 56) and the day-to-day monitoring of patient flow. (3) Bed management strategy. Determining the number of beds required for each unit of clinical activity, using information from business plans and existing usage. It is stated that ``this task is considerably less long term and strategic than it used to be'' (Audit Commission, 1992, p. 56) due to the requirement for flexible determining of bed numbers to match demand. Further, Lying in Wait identifies the responsibility for ensuring that the bed management process is carried out as being with the Chief Executive, along with the decision about the extent to which the tasks can be delegated. The ``placement'' process is the part that is of most relevance to this paper and covers components 1 and 2 of the points above.

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What does bed management involve? This research developed the following model to demonstrate what is involved in the ``placement'' part of bed management, and to bring together many of the initiatives and influences on the process. Essentially, bed management can be viewed as the process of matching up demand for beds with the supply of beds (see Figure 2). Evidence that demand is outstripping supply takes the form of patients waiting in A and E, delayed GP admissions, staff negotiating beds, medical outliers, cancelled electives, transfers to other hospitals, and generally a higher turnover of patients with the subsequent increased workloads for staff. Laing and Shiroyama (1995) argue that tighter performance measures on provider units have been imposed by the 1990 White Paper Working for Patients forcing trusts to look closely at the way they operate. In this context attempts have been made to improve capacity management as well as managing demand (Laing and Shiroyama, 1995). Nevertheless, Figure 2 does not demonstrate the dynamic nature of the situation where both supply and demand are changing minute by minute. Figure 3 is another representation of the activity of bed management, which shows the demand broken into emergency and elective demand, with the waiting lists acting as a ``buffer'' for elective demand. Waiting lists may be viewed as a key element in the balancing of demand and supply:
Rising waiting lists show an imbalance between supply and demand. But since the supply side interacts with demand, simply increasing supply is not good enough in the medium term (Millburn, 1998, p. 20).

Milburn (1998) goes on to describe the demand- and supply-side initiatives proposed. Of particular interest to this study is the promise that ``we will seek to extend many of the innovative schemes developed over the winter to cut bedblocking and allow the uninterrupted flow of elective inpatients''. However, this may not address effectively the balance between emergency and elective activity that is the issue faced every day by bed managers in acute trusts; the issue of what happens to the resources freed by removing ``bed blockers'' being one key element. The total capacity (i.e. numbers of beds) may be subdivided in a variety of ways most commonly into surgical and medical. Yet, depending on the policies of individual hospitals, surgical (and other types of non-medical beds)
BED MANAGEMENT supply of beds
The activities which match supply and demand

Figure 2. Bed management is about reconciling the demand for beds with the supply of beds

demand for beds

DEMAND FOR BEDS

SUPPLY OF BEDS

Bed management
Acute Capacity

Emergency Medical

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Surgical

Elective

Waiting List

Figure 3. Bed management as a dynamic activity

may be used for emergency medical admissions at certain times, so the division between the two types will vary according to demand[1]. This is represented by the dotted line in Figure 3. Theoretical frameworks What do bed managers do? Green and Armstrong (1994) sought to elicit the views of service provider personnel, using semi-structured interviews to ``identify the detailed perceptions of the protagonists'' (p. 13). Their findings are pertinent to this paper in that the methodologies are similar and the findings have considerable resonance in certain ways. The key characteristics of bed management identified were: . A balancing act: It is the management of the balance between demand and supply that leads to many bed managers describing their role as a ``balancing act''. . Never having enough resources: There may be some places where there will never be enough beds (supply) to meet demand the capacity is simply not big enough. . Crisis management: Some bed managers believed that the nature of the job was crisis management. . Knowing what is going on: Bed managers are knowledgeable about what is going on. . In need of authority: Bed managers need authority in order to carry out their role effectively. . Powerful: To be effective, the bed manager has to be continually up to date with the bed state, and be an effective channel for that information.

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Perhaps one of the most recent and graphic illustrations of what a bed manager does was given in a Panorama programme[2] that showed two bed managers from one of the trusts who participated in this study. However, informal reaction to this from other participants in this study indicated that some bed managers felt that it presented a biased picture and that things were not really that bad, or at least not all the time. Information to support the bed management process A major part of the bed manager's role is the complex and diverse process of establishing accurate bed status (including the supply of available beds). This is achieved by the collection of bed data from the wards and comprises a mixture of practices: bed managers visiting wards; ring-rounds to the wards; update calls from the wards; and accessing the Patient Administration System (PAS). The complexity of the role of bed managers with regard to the multitude of data they have to interpret is seen in the fact that they were notified of demand for beds by a number of means and via various media. From a bed manager's perspective, the ``information system'' they engage with may be regarded as a series of information processing steps, not all of which are necessarily automated. This is represented in Figure 4. Information about bed availability is gathered in a bottom-up fashion (this general process is the typical one found in this study): (1) The ward clerks or nursing staff gather information about bed states which includes information concerning: . patients unlikely to leave in next 24 hours;
.

patients who have been discharged or died and have left a vacant bed;

overall bed status assessed

Call for Beds

emergency patients admitted

Elective Booking List

emergency admission placement

Bed Statement sheets
elective patients admitted beds counted

stay

discharge

elective admission

Figure 4. Bed management information flow

bed availability and management

. .

patients likely to be discharged on the next visit by the consultant; delayed discharges.

Bed management

(2) The information is ``processed'' by the ward staff in their assessment of the situation on the ward. (3) The information may be stored informally or on statement sheets. (4) The information is passed (distributed) to the bed manager who gathers an overall view of the hospital/medical directorate situation by ``processing'' the information received from each ward. This may be via face-to-face contact, over the telephone or in a few cases, via a direct network link. (5) Information on emergency admissions is gathered from A and E, GPs, etc. by the bed manager (usually on a fairly piecemeal basis, except when the bed manager comes on shift in the morning). The information is ``processed'' by a matching of new need and current bed status (the minute-by-minute matching of supply to demand). The key factor here is that the situation is rarely stable. (6) Information on elective work is processed as a delivered sheet of potential patients booked in according to consultant. (7) Further information on potential influx is gathered informally a result of past experience, trends, time of year and ``gut feeling''. The resulting actions will depend on the individual trust. However, one of the major difficulties for bed managers concerns the varying and sometimes dubious levels of ``truthfulness'' concerning reported bed status described by bed managers. The bed managers can act to improve the reliability of data using a variety of methods. Those employed in this study included: . ward walking to help ascertain the real state of beds; . personal reputation gained through experience, which meant people were more likely to trust the bed manager and tell them the truth; . negotiation to improve truthfulness by trading favours; . a clinical background, deemed especially important by bed managers who were / had been senior nurses; . knowing which ward staff are most reliable and a source of more truthful data; . checking with the PAS despite its lack of real-time data;
. . .

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informal networks that gave bed managers access to alternative data; adjusting the figures on the grounds of previous experience; disciplining staff, which was occasionally possible for proven acts of misinformation, but went unused.

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There are three important considerations with regard to data worth mentioning here: first, most bed managers mentioned the imbalance of workload over the week as well as seasonal variations; secondly, whilst a few bed managers were compiling regular reports for other people in their organisation, most trusts had no regular reporting of bed management information up the management chain; and thirdly, no evidence was found during the evaluation project that external auditing of bed management data had ever been done at any of the trusts. Results Variations in the bed management function The theoretical frameworks outlined above are revealing of the commonality of practice between bed managers and the general ways in which they collect, store and utilise bed data. However, one of the most interesting features of the research was the variation discovered. The complexity and diversity of bed management practice is clearly revealed by the results discussed below. In outlining these various practices, it is hoped that informed conclusions as to best practice may be drawn. Bed management role In 9 of the 14 cases, the bed management function was headed by a senior nurse, usually of Grade G. The other trusts used business managers spending some or all their time in this role: at two trusts a mixed team of business managers and nurses rotated the Head of Bed Management role through the week. Some of the nurses were on management contracts as Heads of Bed Management. Many of those interviewed who had nursing experience believed this clinical background was important. In addition to their bed management role, some bed managers had other duties to perform often connected with winter pressures initiatives. Variations in scope of responsibility concerned:
.

whether the bed manager was responsible for some or all emergency admissions; how many and which type of beds they had the authority to use; whether they operated alone, as part of one or more teams or had an opposite number in another directorate; if they were expected to take calls from GPs requiring patient admission; whether or not they could cancel electives; whether or not they had the right to discharge patients.

. .

. . .

Despite the theoretical relationship between demand for emergency beds and demand for elective beds there appeared to be little consideration of this. It may be that discussions about the relationship between elective and emergency capacity management are going on at a different level from that of the bed

manager, but there was certainly little awareness of such discussions if they were taking place. The ``balancing act'' aspect of bed management was noted earlier, as was the interrelation between elective and emergency capacity. However, none of the bed managers was involved in the compilation of waiting lists; this was determined by consultants without checking likely bed availability. No evidence was found of an effect of emergency admission rates on the length of stay of electives. Staffing arrangements The staffing arrangements of the bed management function at the different trusts were diverse, varying from four full-time staff on permanent contracts to one part-time member of staff on a temporary contract. Clerical support was sometimes included in the bed management function, but in other places provided as part of a central ``bed bureau'' service which also supported elective admission activity. The amount of support from other functions (e.g. Operational Planning) was also very varied. Hours of duty One major difficulty highlighted was the variation in the number of hours that bed managers had to be available at the trust. In the worst cases up to 60 hours a week was cited; this evidently casts doubt on the bed manager's ability to fulfil their role effectively, due to fatigue. Different trusts had ``active'' bed management covering different times of the day and week: at the time of the study cover varied from a five to a seven day week and in some trusts bed bureau clerks provided cover at weekends. Hours for bed managers stretched from as early as 7a.m. until 9p.m. and although the majority managed to veer not too far from a eight-hour shift, in dire situations a bed manager might be at the trust for 14 hours. Line management Further indication of the varied approaches to bed management, and the position it occupied in the trusts, is given by considering the line manager to whom the most senior bed manager reported and their parent directorate. This varied so widely that no two bed managers reported to a line manager with the same title in any of the trusts. Similarly, the directorate employing the bed manager differed markedly. Difficulties of the job Despite the diversity of bed management, the people exercising the role of manager had some shared experiences. One bed manager expressed doubts as to whether beds could be ``managed'' as they represent a potent source of power within the organisation; the approach was rather to try to control situations. Consequently, many of the bed managers in this study appeared to be very stressed on a regular basis. Most put this down to the nature of the job: juggling

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with resources that were simply not sufficient; involvement in interpersonal negotiations that could sometimes turn nasty; and the amount of work to get through. In addition, bed managers could also feel isolated in the organisation, particularly if they had been used to working as part of a large team. ``My job is to make myself unpopular!'' As mentioned above, some managers were regularly working well in excess of their contracted hours. Although it is appreciated that such stresses and long hours are evident in many other parts of the health service, the importance of the bed management role in achieving the objectives of the trusts concerned was perhaps not clearly understood by those to whom the bed managers report. This may be related to the strategic/ operational level of the bed manager function and its staffing level in a trust. As a result, several bed managers mentioned the chaos that had ensued when they had been on leave particularly those whose role was primarily operational in nature. By contrast, those with a more strategic role were still stressed but felt more in control and also perceived more variety in their jobs. Doing a good job During a discussion at a bed managers' meeting about measures of performance, the difficulties faced by bed managers in assessing whether they were doing a good job or not came to light. They often felt frustrated because ``the job has no beginning or end''. This led to a lack of job satisfaction for some individuals. There was a sense that they were not appreciated by clinical staff and were concerned at the apparent lack of interest (and in some cases lack of understanding) shown by other people in the organisation (including those more senior); the lack of specific trust objectives for the bed manager function contributed to this sense of uncertainty. However, bed managers had set their own personal goals which included ``to have enough beds free at the end of the shift to get us through the night'', and ``consuming our own smoke''. The context of bed management Increased interest in bed management in Greater Management was part of a range of efforts to address winter pressures. All Chief Executives agreed a policy for Emergency Admissions in October 1997[3], and its effectiveness was monitored throughout the winter by a dedicated co-ordinator who reported regularly to Chief Executives and the Regional Office. Typical measures taken included: . admissions/assessment units for those sites that did not already have them; . discharge lounges again already in place at some sites; . discharge co-ordinator liaising with social services; . extension of hours of community nurse team, social services, home-help; . intermediate-care ward (lower intensity ward to take acute patients awaiting social package);

. .

. .

extended testing unit hours (e.g. blood testing unit); escalation status that could be called in circumstances of impending bed shortage, under which all patients may be reviewed; ``tidal'' wards with beds that can explicitly be used for either medical or surgical patients according to demand; ``swing'' wards surgical wards with designated beds to be used for medical patients when necessary; extra ward staff; extra beds in A and E and hospital in general;

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Discussion Scope of responsibility This study revealed a considerable variation in the amount and scope of responsibility given to the person with the title of ``bed manager'' in each trust. The varying degrees of responsibility given to bed managers can be broadly classified into three categories: (1) Strategic. This is where the management of beds as a resource (for both emergency and elective admissions) is seen as a strategic priority and the bed manager is involved in discussions about relevant issues at a senior level. The Chief Executive would be personally involved, would know the bed manager and show an interest in the role. In this situation, it is expected that a bed management function with more than one member of staff would be present one person could not fulfil both the strategic and the day to day operational role in a general acute trust. In this case, the bed management function had authority to use any (or almost all) beds in the trust and was not limited only to medical beds. This research suggests that such people are essentially ``managers'' they spend time considering more strategic aspects of bed management and developing initiatives to try to improve the whole process. The managers can, of course, usually only be afforded this luxury when staffing levels in the bed manager function are relatively high, so that more routine aspects can be delegated for at least some of the time. (2) Mixed. Here the bed manager is involved in some strategic issues; perhaps relating to winter pressures activities, but also bears the brunt of the day to day operation of the bed management function. Hence, the bed manager may be involved in counting beds. In many cases, this duality of roles caused considerable pressure for the individuals involved. This was the situation in the majority of trusts in this study certainly those where bed management was a permanent feature, rather than a temporary post. The personalities involved in this type of bed management tended to be nurses, who are used to ``coping'' with a number of demands (Audit Commission, 1992; Davies, 1996). These ``copers'' tend to spend almost all their time (and often more than their

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contracted hours) on the fire-fighting and tactical aspects of the job coping with placing patients. (3) Operational. In this category the bed manager is there primarily to monitor the bed state and allocate beds to patients as appropriate. There is little or no strategic involvement, corresponding to Lying in Wait's (Audit Commission, 1992) classification of ``day-to-day decisions''. The personalities in this role were also ``copers'' but often dealing with such complex or vast operational issues that they had no time to think at a higher level. These bed managers were not lacking in interest or skills related to their role, but some were either so busy or so new in the role that they did not have time or inclination to look further. The above are to some extent stereotypes, and in times of extreme pressure even the more managerially oriented bed managers may be forced to adopt a fire-fighting stance. However, there still appears to be some relationship between the bed managers who were strategically oriented and the time that they had been doing the job. This suggests that there may be some evolutionary model of bed management that could be developed once a more substantial research base has been developed. The conflict between strategic and operational issues is the key one for most bed managers and it is the operational issues that always take precedence because there is no other option. This is crisis management as well as a balancing act (see above) and is supported by evidence gathered in this study. In general the scope of the role of bed manager varied considerably from trust to trust and although this study reinforces conclusions drawn in Lying in Wait in 1992 (Audit Commission, 1992), the fact that bed management as a function appears not to have moved on significantly since then could be of considerable concern. It was also found that just as organisational structures vary between trusts, so does the position of the bed management function within these structures. With no trust having a central admissions planning function dealing with both elective and emergency admissions, it was not possible to assess the benefits of this approach, although they seem intuitively to be significant. The perceived lack of bed management objectives within trusts along with the varied line management arrangements and frequent lack of reporting, indicate that most trusts do not appear to be using bed management as a major strategic tool. The bed manager's role There also appears to be some relationship between the interest of the Chief Executive in bed management and the strategic orientation of the bed manager function. Not only does interest bring a profile, but it also appears to bring resources in the form of more staff, if the experience of some trusts can be generalised. However, this may also depend on the background of the bed manager him/herself and skills in putting forward a coherent case for support.

In turn, this may also relate to the commitment of the line manager and the relative importance of bed management to them. Little evidence of co-ordinated capacity and operational planning was found. The issues of supply and demand for beds described do not appear to be clearly understood or articulated. This may be due to the current spread of responsibility for aspects of the bed management function across differing organisational functions. Further, it appears to be difficult to ascertain whether the bed manager is doing a good job. Lying in Wait (Audit Commission, 1992) suggests that turnover interval is related to units having a bed manager. However, the change in environment and resource availability since 1992 may mean that turnover levels are much lower now anyway, due to overall pressure on capacity. During this study a variety of job descriptions and bed management policies were gathered, but none specifically include measurable performance criteria. It can be presumed that this is due to the difficulties in defining such criteria and the lack of theoretical material to support this. The problems and potential of bed data As mentioned previously, emphasis has been placed in the study on the collection, recording, use and interpretation of data pertaining to the bed management process. This relates to the complexity of the job and the type of information system required to assist bed managers in their job. Maintaining a balance between sitting in the office and walking the wards was a considerable issue for some bed managers. Although some bed managers highly estimated the efficacy of telephone calls for data collection, nevertheless, they felt under pressure to be seen ``out and about'' on the wards. One of the key problems identified by bed managers in relation to the nature of their data handling concerned the flows of information, which in turn reflected the numerous peaks and troughs in patient influx and demand for beds. The fluidity of the situation and the constraints on data collection mentioned above would make any attempt to treat bed numbers as real numbers in real time impractical. The general feeling amongst the bed managers was that the bed state data are as accurate as is feasible but cannot be regarded as totally reliable or self-explanatory at any point in time. Thus a good deal of skill and experience is required for interpretation of the information. Such an interpretation includes an element of prediction. Indeed some bed managers have included in their paper-based systems a column indicating beds that are likely to come up. This suggests an implicit attempt to forecast the immediate future, and is something that could bear fruit if extended. Few trusts showed any evidence of systematic consideration of the fluctuations in demand evident in the study. It is clear that if the bed management process was improved and the bed data integrity and accuracy thereby assured, there would be considerable potential for forward planning using IT to help cope with the peaks and troughs which characterise the situation at present. Although there are variations in the pattern of emergency

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admissions throughout the week (including weekends), the pattern does not appear to be as varied as that of elective admissions in most trusts, if the anecdotal evidence from this study is accurate[4]. Spreading elective work over the week might ease the peak pressures on bed capacity, but would clearly have effects on the other resources required for elective work (for example, theatres). As ward rounds, specialist testing and pharmacy dispensing etc. do not always occur on weekends, or not to the same level as during the week, discharges are often delayed over weekends. Weekend operation during busy periods could increase the supply of beds. There are also visible trends during the day, with emergency admissions often peaking in the late morning[5]. Again, some of this could be eased by more frequent or appropriately timed ward rounds to ease the discharge process, as well as increased flexibility or speed of response from other services (e.g. pharmacy). Discharge lounges have addressed some of these issues, but may have simply disguised the issues causing the delay rather than attempting to address them. Despite this, however, at present there is only one trust in the region using any formal form of forecasting of emergency admissions having undertaken a systematic analysis of the data they recorded and the associated procedures following the publication of Lying in Wait in 1992 (Audit Commission, 1992). Conclusions and issues for further consideration Contribution of this paper It is worrying that the severity of the problem of bed management may not be fully appreciated especially given the good crisis management that took place, despite pessimistic expectations during the course of this study. However, whilst peak winter pressures were less severe in 1997/98 than in previous winters, many believe the mild weather and absence of a widespread influenza outbreak were probably significant factors. Thus improvements which have undoubtedly been made cannot be taken to be sufficient for future (more severe) winters. With this in mind, this paper has sought to contribute to the improvement of the bed management process and alert health care professionals to its potential and problems. This has been effected by developing a description of the role of bed manager and a picture of the process of bed management whilst emphasising the complexity and diversity of both. Need for systematic attention The non-existence of standards of bed management practice is taken to reflect a lack of systematic attention paid to this role. Whilst this is not surprising given the relative newness of the job and function if capacity is to be managed effectively with due regard to the quality of patient care, health care professionals might do well to consider the methods currently used to allocate beds and expedite appropriate discharges. The recent initiatives on waiting lists (national targets to simultaneously increase the volume of elective work whilst coping better with emergency demand and improving the quality of

care) will undoubtedly serve to focus attention on these issues. An initial starting point seems to be the move to integrated management of emergency and elective beds. Immediate measures Further, our study suggests that one area where measures may be fairly immediately effected is the discharge process. The problems associated with the discharge of patients are well documented and relate to co-ordination, communication and the provision of information to patients. In order to improve the sense of seamless care and emphasise the totality of the communication network, it has been suggested that patient ``pathways'' be constructed (Lyne and Williams, p. 54). By ensuring appropriate discharge takes place, the quality of care can be raised and the workload reduced by cutting the proportion of rapid re-admission. There were signs that some trusts were starting to do this. In addition, the improvement to the management of beds need not and probably should not stop at the hospital gates. Bed managers can play an important role in the link with ``client'' GPs in shaping patient expectations, smoothing short term demand peaks, acting as a central point of contact and reducing hospital doctors' workload. Future research This paper has provided data that can contribute to discussions necessary for policy development and adoption. It has been suggested that it may be possible to develop an evolutionary model of bed management and further research will take this as a focus. The potential of co-ordinator and facilitator posts at regional level may improve visibility of bed management at Chief Executive level as well as facilitating the bed managers' local network and dissemination of best practice and the results of local initiatives. What is more, systematic consideration of the factors leading to uneven demand for and supply of beds, as well as means to reduce such irregularity, might be beneficial. Further research into bed management that concentrates on the patient's pathway through the hospital and thereby avoids the fragmentation of views from clinical areas is not only pertinent, but essential. Essentially, there needs to be more work on improving capacity and managing demand. With this in mind, the potential benefits of applying operational research methods in the clinical environment with regard to the reduction of queue length and waiting times have been suggested elsewhere (Aharonson-Daniel et al., 1996). Thus, aspects of initiatives such as Patient-Focused Care and Re-engineering might be appropriate, although they do have limitations and weaknesses.
Notes 1. There may also be beds which are outside the total capacity shown here, commonly referred to as ``ring fenced'' beds which are completely outside the control of the bed management function. Typically these will include ICU beds and those related to tertiary centres, but may also include maternity and psychiatry in many trusts.

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JMM 13,4

2. 3. 4. 5.

BBC1, 20 October 1997. Greater Manchester NHS Trusts Emergency Admissions Policy/Practice, 23 October 1997. This study has not attempted to consider variation of demand in detail. This is anecdotal evidence, not the result of a systematic analysis of data.

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