Delayed transfers of care (DToC) cost providers £173 million in 2016/17, according to the NHS providers’ audited accounts. This is up 19% from 2015/16, and it is highly likely that the full cost is much higher than these estimates suggest.1

In a statement to parliament on 3 July, Jeremy Hunt stated: “Government is clear that no-one should stay in a hospital bed longer than necessary: it removes people’s dignity, reduces their quality of life; leads to poorer health and care outcomes for people; and is more expensive for the taxpayer.”2

 The Government’s mandate to NHS England for 2017/18 set a target to reduce the national delayed transfers rate to 3.5% by September 2017 – a level it has not reached since the fourth quarter of 2014/15.3

In July the government laid out targets requiring councils nationally to reduce the rate of delayed discharges attributable to social services by 53% from February 2017 levels in 2017-18, with councils deemed to be lower performing tasked with achieving a two-thirds reduction.4

What are DToC?                                                    

A delayed transfer of care, often called ‘Bed blocking’ by the media, occurs when a patient is medically fit for discharge from acute or non-acute care and is still occupying a bed. According to NHS England, a patient is ready to depart when:5

  • A clinical decision has been made that patient is ready for transfer AND
  • A multi-disciplinary team decision has been made that patient is ready for transfer, AND
  • The patient is safe to discharge/transfer.

DToC are a significant concern for multiple reasons, and the impact is felt across the wider health system:

  • Impact on frontline staff – Once a patient is well enough to leave hospital, staff want to treat other patients with greater needs.
  • Impact on a patient’s health –Longer stays in hospital are associated with increased risk of infection, low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increase their odds of re-admission.
  • Impact on older patients – ‘A wait of more than two days negates the additional benefit of intermediate care, and seven days is associated with a 10 per cent decline in muscle strength’.
  • Impact on budgets – patients that are kept in hospital longer than necessary cost the hospital staff time and space that should be used for something else.

What is the government doing?                                                                        

Funding

The spring 2017 Budget announced an additional £2 billion to councils in England over the next three years to spend on adult social care services. However, health secretary Jeremy Hunt has threatened to review allocations for 2018-19 for those councils that fail to hit their delayed discharges targets, a move heavily criticised by ADASS and the LGA.

There is also increasing pressure on local councils to use the Better Care Fund to improve the interface between the NHS and social care, with Better Care Fund plans required to include a target for reductions in DToC across Health and Wellbeing Board areas. The 2015 Spending Review and Autumn Statement announced an increase to the BCF of £1.5bn by 2019-20. It also set out plans to integrate health and social care across the country by 2020.

Data collection has changed

As of April 2017, data on the number of patients delayed on the last Thursday of the month is no longer being collected and has been replaced by the DToC Beds figure. This is calculated by dividing the number of delayed days during the month by the number of calendar days in the month and is more representative of the entire month rather than providing a view on one particular day.

Government Guidance on reducing DToC

‘Monthly Delayed Transfer of Care Situation Reports: Definitions and Guidance’5, produced by NHS England, DH, ADASS, LGA and ECIP, is currently being refreshed in response to a number of ongoing operational issues and concerns from local health and social care systems.

The solutions are far from simple                                                                    

As is typical of our complex health and care system, the solutions are not simple. Indeed, the data on which key government funding and structural decisions have been made, have been critisised for being inaccurate, and for masking wider issues.

Furthermore, many have been critical of NHS trusts who have issued fines of up to £280,000 to councils for delayed hospital discharges since 2016 using schedule 3 of the Care Act 20146, fearing that this blame culture will compromise relationships between the NHS and social care.

Set against a backdrop of continued public sector austerity and growing demand for hospital care, many are questioning whether the government’s ambitious targets are achievable. And with a recent ADASS survey showing that just over half (52%) of social care directors who had set delayed discharge reduction targets in line with national expectations for social care and health, consider these to be realistic for both services – there is clearly a concern within the sector.

A heavy-handed approach from health secretary Jeremy Hunt who has threatened to review allocations for 2018-19 for those councils that fail to hit their delayed discharges targets, has also been heavily criticised by ADASS and the LGA.

Set against this backdrop, below are some learnings we can take away.

Unpack the data to form the solutions

Social care is often viewed as being the main culprit for causing delays with transfers of care. This is mainly due to the steep rise in the proportion of delays that are now attributable to social care – with data showing an 84 per cent rise since December 2010. The marked rise in delays due to ‘awaiting a care package in own home’, up 45.3% in comparison with the previous year – also points to social care as being the root cause of delayed transfers. ‘Awaiting completion of assessment’, ‘awaiting nursing home placement or availability’, ‘awaiting residential home placement or availability’, ‘awaiting public funding’, and ‘awaiting community equipment and adaptations’ have also seen increases of over 10%.

However, it’s important to remember that the majority of DToC (56.5% recorded in September 2017) occurred because of issues in the NHS, and that delays that initially look like they can be attributed to a local authority social services, may also be the responsibility of the NHS. For example, if a care package involves the services of a district nurse or physiotherapist, who is not in place when a patient is ready to be discharged, this delay is the responsibility of the NHS, not of social care.1

Streamline internal processes

Whilst improving integration between health and social care is vital to meet DToC targets, it’s important that both the NHS and social care review their internal processes and procedures so they are more effective in discharging people from hospital. Chief Executive at the Nuffield Trust, Nigel Edwards, states: “A complex array of factors are at play and poorly designed processes, high volumes of work, shaky administration and a lack of clear pathways can all exacerbate the problem. These range from simple issues, such as having the drugs ready for the patient to take home, to more complex ones, such as delays in getting diagnostic results or a lack of therapy services at weekends.”7

Clearer guidance to improve Data

DToC have a tight definition and as a result the reported figures often only represent a partial picture of the volume of patients that could be cared for in other settings. The Kings Fund states: “There are limitations to the data. It is not clear whether all providers are using the definitions of delayed transfers of care or reasons for delay in the same way; small differences in interpretations could lead to large changes in reported numbers.”8 The revised ‘Monthly Delayed Transfer of Care Situation Reports: Definitions and Guidance’ due to be published later this year, will hopefully provide the clarity needed to provide a more accurate picture of DToC on which to form robust solutions.

Learn from areas with fewer delays

The huge variation in local government and NHS performance in managing delays is an area for concern, with just 24 local authorities responsible for over half of all delayed discharges to social care. Whilst the additional targeted funding to tackle this variation will be vital in reducing variation, so too will be sharing best practice and learning from areas with fewer delays.

 

 

References

  1. Delayed transfers of care in the NHS, House of Commons Library, briefing paper, Number 7415, 20 June 2017

http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7415#fullreport

  1. Houses of Parliament, Delayed Transfers of Care: Written statement made by Jeremy Hunt on 3 July 2017

https://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2017-07-03/HCWS24/

  1. Department of Health, The Government’s mandate to NHS England for 2016-17, December 2015

https://www.england.nhs.uk/wp-content/uploads/2015/12/05.PB_.17.12.15-Annex-A-Mandate-to-NHS-England.pdf

  1. NHS Indicators: England, October 2017, House of Commons Library, Number 7281, 3 October 2017

http://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7281

  1. NHS England, Monthly Delayed Transfer of Care Situation Reports – Definition and Guidance, revised on October 2015

https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2015/10/mnth-Sitreps-def-dtoc-v1.09.pdf

  1. Community Care Magazine, October 2017

NHS trusts have fined councils up to £280,000 for delayed discharges

  1. Nuffield Trust website, February 2017

https://www.nuffieldtrust.org.uk/resource/what-s-behind-delayed-transfers-of-care

  1. The Kings Fund, Delayed Transfers Care – Quick Guide, November 2015 ,https://www.kingsfund.org.uk/publications/delayed-transfers-care-quick-guide