Clearly there had been massive changes between 1989 and 1994 in the planned size of the hospitals under the control of the Trust. The proposed number of beds had gone from 1650 beds in 1989 down to 701 in 1994. What were the reasons for more than halving the proposed number of beds in five years?
There are two interpretations. The reasons officially given were that;
• there had been major changes in clinical productivity (shorter stays for in-patients and more day surgery), and;
• there would be no mental health in-patient provision at the Colney Lane site (to be provided instead by the Norfolk Mental Health Care NHS Trust).
Changes in clinical productivity had taken place over a long period. The average length of stay at the St Stephen's hospital had been successively reduced from 31 days in 1901, to 22 days in 1924, to 19 days in 1938, to 5.9 days in 1990/91 (Cleveland 1948, 28 and NHA 1992, 9). The last figure excludes mentally-ill patients and NHA 1992 expected it to fall even further to 4.4 days by 1995 (NHA 1992, 9).
But this was extremely optimistic given that the average length of stay at the national level was beginning to level out. A report in 2004 by the Office of National Statistics showed that the average length of stay in hospitals in England had fallen from just under 8.5 days in the early 1990s to about 7 by 1997 but it had remained at 7 over the next five years through to 2002/03 (Office of National Statistics 2004, Chart 6)
Furthermore the 701 beds proposal was at the very bottom level of the estimated requirement being predicted in the first half of the 1990s. In 1994 a survey of bed requirements had been carried out by Stuart Wooler of the London School of Economics and Dr Bill Kirkup of NHS Executive Northern and Yorkshire Regional Office. The Wooler/Kirkup study was carried out at the request of Paul Kemp (Director of Finance and Performance, Eastern, Department of Health) and it gave three 'demand scenarios' - low (701 beds), a medium (of 790 beds) and a high (910 beds) (NNHCT 1994, Appendix 1). Clearly the figure chosen in 1994 was at the lowest end of this demand projection.
So changing clinical practices could not justify the massive downsizing. An alternative explanation for the downsizing is one of affordability - namely, that the size of the hospital was being squeezed to fit what the Trust's budget could afford in the light of the higher cost of PFI capital. This was alleged to be the case across the country (see Pollock and Dunnigan 2000 and Sussex 2001, 67). It was being argued that, in the second half of the 1990s, PFI schemes were being designed on the basis of lower projections of growth, greater reductions in lengths of stay and higher levels of occupancy than national trhends could justify. It was suspected that; "the severe downsizing of NHS hospitals in PFI schemes is partly in order to leave room for a higher private sector cost of capital" and Jon Sussex added that; "This interpretation is supported by unattributable conversations the author has had with NHS managers and their management consultant advisers involved in PFI schemes" (Sussex 2003, 71).
Thus there are firm grounds for thinking that the size of the Norfolk and Norwich University Hospital (NNUH) was being squeezed to match expensive PFI projects to the budget. The Select Committee on Health has said that; "What is not in doubt is the fact that lack of transparency in the PFI process has been partly responsible for the impression that PFI can be equated with a reduction in the number of beds" (UK Parliament 2002, paragraph 77). This was certainly true of the discussions about the NNUH in the Select Committee in 1999. There was considerable confusion caused by the testimony of David Stout (then Director of Resources at the Norfolk and Norwich Health Care NHS Trust) before the Committee in May and July 1999. He confused the value for money and affordability arguments by claiming that there would be a saving from having fewer beds in the new hospital than in the old hospitals being replaced (see UK Parliament May 1999, paragraph 55)
The suspicion that the proposed size of the NNUH was being squeezed to fit the high cost of money is reinforced by what happened following the approval of a 701-bed hospital in 1994, namely a rapid increase in the proposed size - first, to 809 beds in September 1996 and then to 953 beds in December 1999. And yet in spite of these increases, in 2001, the NNUH was said to be not alone among recently completed PFI hospitals in running at an undesirably high level of capacity that was adversely affecting its performance (PPP Focus; Health quoted in Edwards P et al 2004, 146). Between 2003 and the beginning of 2005, the NNUH was said to be operating at an average occupancy of over 90% compared to a national average of about 86% (NNUHT March 2005,21 and NAO 2005, 11)40.
Now the next sub-section returns to the chronology
40 . In March 2005, it was reported that some patients were being diverted to another hospital 30 miles away because the NNUH was full (Eastern Evening News, 17 March 2005)