One of the central arguments in Better Health for London was structural: too much NHS activity in the capital was happening inside hospital walls, and too little in GP surgeries, community clinics and people’s own homes. The 2014 report, produced for the Mayor of London under the chairmanship of Professor Lord Ara Darzi, treated this as a design flaw as much as a funding one — and recommended a deliberate shift of care out of hospitals, alongside reconfiguration of urgent and emergency services. Ten years on, national bed and attendance data give a way to test that recommendation against what actually happened.
The 2014 case for moving care out of hospitals
The logic behind the recommendation was straightforward. If more conditions were caught early and managed in primary and community settings — supported by better GP access and stronger out-of-hospital services — fewer people would need to be admitted, and hospitals could concentrate on the cases that genuinely required specialist inpatient care. This was framed as both a quality improvement and a capacity strategy: London’s hospital estate, the report argued, could not simply keep absorbing rising demand.
What happened to hospital bed numbers
On paper, the shift the report called for has been happening for a long time — just not for the reasons it intended. The total number of NHS hospital beds in England more than halved over the thirty years leading up to 2019/20, falling from roughly 299,000 to around 141,000, with acute inpatient beds down by 63% since 1960. That decline reflects shorter hospital stays from medical advances as much as any deliberate community-care strategy. As of March 2024, the total number of hospital beds across the UK stood at around 160,642, with England accounting for about 130,528 of them.
The consequence is that the remaining beds are running far hotter than before. Bed occupancy rates, which frequently exceeded 90% even before the pandemic, reached a record high of 93% by the end of 2023/24. A system designed around scarce beds and a genuine shift of demand into the community would expect occupancy to ease as capacity better matches need. Instead, the data shows a shrinking bed base absorbing rising pressure — the opposite of what a successful "care out of hospital" strategy would look like in the numbers.
A&E attendances tell a similar story
If care had genuinely moved into primary and community settings at scale, accident and emergency attendances would be expected to flatten or fall relative to population growth. National figures show the reverse. England recorded 27.4 million A&E attendances in 2024-25, a 4.0% increase on the year before, with London’s departments among the busiest in the country — recent data points to some of the three busiest months for A&E staff on record occurring in 2024.
Performance against the four-hour standard, under which 95% of patients should be admitted, transferred or discharged within four hours, has not been met nationally in any month since July 2015 — the year after Better Health for London was published. By 2024/25, only 59% of attendances at major, consultant-led (Type 1) departments were seen within four hours. The share of attendances waiting longer than four hours rose from 8.1% in January 2013 to 42.4% by September 2023. Waits of twelve hours or more from the decision to admit through to actual admission have grown sharply too: 1,880,272 such attendances were recorded in 2024-25, up 6.9% on the previous year.
Where London-specific reconfiguration did move
Not every strand stalled. A year after publication, the London Health Board reported real progress on GP access, with many practices offering 8am–8pm appointments, backed by new primary-care investment through schemes such as the Prime Minister’s Challenge Fund. Individual hospital reconfigurations have also progressed, if slowly: St Mary’s Hospital is working towards a new 800-bed facility by 2035 as part of the wider New Hospital Programme, and St Helier Hospital secured £57 million for a major A&E expansion after inspectors found it routinely operating at more than ten times its intended capacity. Proposals for A&E closures and standalone urgent care centres elsewhere in London have, by contrast, drawn sustained concern over patient safety and potential effects on emergency deaths — a reminder that "reconfiguration" covers both expansion where pressure is worst and contraction where it is contested.
Recommendation versus evidence, ten years on
| 2014 recommendation | What the decade of data shows |
|---|---|
| Shift care out of hospitals into primary and community settings | Bed numbers have fallen, but mainly from long-run efficiency trends, not a demonstrated community-care substitution effect |
| Reduce pressure on hospital beds | Occupancy has risen to a record 93% by 2023/24 — less spare capacity, not more |
| Ease demand on urgent and emergency care | A&E attendances are rising (27.4m in 2024-25) and the four-hour standard has been missed every month since 2015 |
| Improve GP access as an alternative to A&E | 8am–8pm access expanded meaningfully in the years immediately after the report |
| Reconfigure hospital and urgent-care estate where needed | Some individual projects (St Mary’s, St Helier) are moving, but many sit inside a delayed national programme, and contested closures remain unresolved |
What this means for reading "ten years on" claims
The honest reading of this evidence is mixed, not simply a failure or a success story. Genuine progress happened on GP access and on specific, capacity-driven hospital investments. But the headline ambition — a system where more care delivered outside hospital walls visibly eases the pressure inside them — is not what the bed occupancy and A&E figures show a decade later. Beds have shrunk for reasons mostly unrelated to the report’s community-care agenda, while occupancy and emergency demand have both climbed. For anyone assessing what Better Health for London actually delivered, hospital bed and A&E data is one of the clearest places where intention and outcome visibly diverge.