Patient characteristics and clinical caseload of short stay independent hospitals in England and Wales, 1992-3

Method

We identified independent hospitals with operating theatres open at any time in 1992-3 from the lists of the Independent Health Care Association4 or the Directory of Independent Hospitals and Health Services.6 We collected information on all admissions and discharges from each hospital for a sample period, 1 April 1992 to 31 March 1993. For comparability we allocated the hospitals that provided data in 1986 the same data collection periods in 1992-3. For hospitals opened since 1986 the length of sample periods was set so that, based on the number of beds in the hospital, roughly 100 admissions would be sampled from each hospital. The time of year of sampling was set to obtain, within a region, a similar amount of data each month.

We estimated activity for the whole year by weighting the sample numbers according to the length of the sample period and time of year, correcting for the absence of data from 16 hospitals that were known to have been open for part of the year. Because of weighting and rounding of estimates the totals in the tables do not always equal the sum of the components.

Results

In all, 217 hospitals were active for some or all of the year. Another seven hospitals originally identified were ineligible or had closed down. All but three hospitals had usable data available on their activity. These 214 contained 11 319 beds (mean 53, range 8-267). One hospital with 48 beds was missed from the study. The managers of 12 others (587 beds, mean 49) refused to cooperate. Thus data were obtained from 201 (93%) of the 217 hospitals.

From the sampled 30 185 records we estimated that 678 703 patients were treated as inpatients or day cases in the year. This was more than double the number in 1981 (323 440), and 35% more than in 1986 (503 260). Our estimate for the 31 Nuffield hospitals in England and Wales differed from the actual number by only 0.4%. Our estimated number of abortions was 4% less than the aggregated quarterly numbers in non-NHS hospitals in England and Wales reported by the Office of Population Censuses and Surveys.7

There were 429 172 (63%) inpatients, which was 7% more than in 1986 (401 920), and 249 531 (37%) day cases, 154% more than in 1986 (98 390).2 A higher proportion of patients were United Kingdom residents (96%) than in 1981 (84%) and 1986 (91%) (table I). The number of overseas patients almost halved.

Nearly half the beds were in hospitals in the four Thames regions. There was a 10-fold difference between the region with the highest and lowest level of provision (table II). The numbers of beds increased in all regions between 1986 and 1993 by an average of 11% (boundary changes distorted the distribution between North West Thames and North East Thames). Correspondingly, all regions showed increased rates of use by residents. The rate of use nationally rose by more than the increase in bed supply after 1986, largely because of day case surgery. Rates varied fivefold between the lowest and highest regions.

When women having maternity care or abortions were excluded, the age profile of patients was older in 1992-3 than previously: 56% were over 45 years in 1992-3 compared with 50% in 1981 and 1986, and 19% were over 65 years (table III). The aging of the hospital population partly reflects demographic trends, and government incentives to the retired to maintain health insurance probably increased demand modestly.

Apart from abortions, the clinical activity was still mainly elective surgery. Lens operations, endoscopic examinations, heart operations, and non-surgical treatments especially chemotherapy for cancer, showed the largest increases since 1986 (table IV). Although overall there were fewer overseas patients than in 1986, they accounted for 3746 (26%) of those having heart procedures, including 2622 (41%) coronary artery bypass grafts.

When the 14 hospitals whose main activity was termination of pregnancy were excluded the average bed occupancy was 48% (regional range 42%-60%) compared with 55% in 1986 (table II). Occupancy was 41% in hospitals with charitable status and 53% in hospitals run for profit.

Only one in 20 cases were funded by the NHS through contracting out (table V). This figure cannot be verified from NHS sources because the data are not available centrally. The method of payment was known for 96% of cases. After vasectomy and abortion cases were excluded (for comparability with previous surveys) more residents of England and Wales paid partly or wholly through health insurance than before (90% of males and 86% of females; table VI). Nevertheless, nearly 70 000 patients paid for themselves or were paid for. Proportionately more of the people past the retirement age paid for themselves. Even so, four out of five men and nearly two in every three women over 75 paid through insurance.

Most patients (641 649 of 655 350) (97.9%) were discharged home, which reflects the large amount of elective treatment. The number of patients who died was low (2647, 0.4%) as these hospitals do not provide much terminal care, and only 131 patients were transferred to NHS hospitals.

Discussion

Despite the NHS reforms, waiting list initiatives, and investment in day surgery, independent hospitals treated appreciably more patients in 1992-3 than they had six years earlier and dealt with a similar range of conditions. However, their capacity was considerably underused. Staffing resources may be a limiting factor, and this factor may increase if corporate loyalty to NHS trusts grows among consultants. The number of NHS consultants in England and Wales in the acute specialties with higher potential for private practice (anaesthetics, general, cardiothoracic, paediatric, plastic, and orthopaedic surgery; neurosurgery; ophthalmology; obstetrics and gynaecology; and urology) expanded by 12% between 1986 (5805) and 1992 (6709) (Department of Health, personal communication), while the caseload of independent hospitals rose by 35%.

Independent hospitals are likely to continue to operate below capacity because the number of people covered by private medical insurance has stopped rising,10 the waiting times for NHS treatment are not rising, and hospital trusts want to capture public and private sector business. Furthermore, this survey showed little evidence that NHS purchasers, the first general practitioner fundholders, and local health authorities were contracting with independent hospitals, nor that independent hospitals had been creating niches among certain patient groups or for certain treatments.

Geographical differences in use remain wide, mirroring levels of uptake of private health insurance. Higher rates of provision and use in the Thames regions may reflect more NHS investment going outside London and the reduction of NHS beds in London.

The demand for treatment from overseas patients fell, except for some technologically advanced procedures. Perceptions of the cost or quality of care in the British private healthcare sector may have changed, and provision of specialist services in other countries may have grown.

Data on recent NHS pay bed activity are not yet available so total private sector activity relative to the public sector and NHS paybeds' share of it cannot be calculated. In the first year of NHS trusts, 1990-1, an estimated 81 366 patients used pay beds in NHS hospitals in England, 21 766 of them as day cases (Department of Health, personal communication). In the face of growth in activity of independent hospitals NHS pay beds probably remained minority providers of private acute care.

We thank Private Patients Plan Medical Trust for funding this study and Dr Harry McNeilly and Mr Martin Kirkham for facilitating it; Barry Hassell and John Randle of the Independent Health Care Association for help in mounting and maintaining the survey; the chief executives and managers of cooperating hospitals; ACT Medisys for additional programme development; and Michelle Crossland, Betsy Kohler, Karen Graves, Fran Bullivant, Daniel Fall, Sheila Bray, and Deborah Owen of the Medical Care Research Unit.

The Medical Care Research Unit is funded by the Department of Health. The views expressed in this report are those of the authors alone.