Managing transfers of care: frequently asked questions

The LGA is continuing to work with councils and the sector to identify the challenges and barriers and work towards positive solutions that maintain a focus on the people that use the services.

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‘Behind every delay is a person in the wrong place’

Delayed transfers of care, sometimes inaccurately referred to as ‘bed-blocking’, occur when a patient is ready to leave hospital but is still occupying a hospital bed.

According to NHS England, a patient is ready to leave when:

a) a clinical decision has been made that patient is ready for transfer AND

b) a multi-disciplinary team decision has been made that patient is ready for transfer, AND

c) the patient is safe to discharge/transfer.

Delayed transfers of care are reported as a number of days where a patient delayed is occupying a bed. But it is important to remember that behind every ‘delayed day’ is a person in the wrong place for them. Local care and health systems are committed to minimising unnecessary hospital stays and providing the best social care support for people who need it, ensuring better outcomes of care for individuals.

Patients may be delayed for a variety of reasons. For example, waiting for onwards care at a community NHS facility such as a community hospital. Or waiting for social care to be arranged at a residential or nursing home or for a care package at home to be developed. Often delays can arise simply because a patient’s assessments aren’t completed before they recover. Completing a needs assessment of onward care generally requires agreement from a multidisciplinary group of hospital clinicians, social workers and other care workers.

Agreeing that a patient is fit for discharge, as well as acquiring a care package and getting paperwork completed on time, can be a lengthy process. Other factors can also come into play such as disputes between families/patients and providers concerning where the patient should be transferred; waiting for equipment to be installed in the community; awaiting public funding and housing issues. More recently however it is recognised that it is not generally in the patient’s best interest to remain in an acute hospital whilst this is going on as older people can quickly lose their function and mobility and can be at risk of further medical decline.

In 2016/17 there were 2.3 million delayed transfer days in England, an average of around 6,200 every day of the year. The average number of delayed days for 2016/17 was 25 per cent higher than the previous year.

Daily DTOC beds breakdown by care organisation (Mean) (April 2015 to Sep 2015) for England
Daily DTOC beds, all (breakdown by care organisation) (Mean) (from April 2015 to September 2017) for England

 

Blue: England DTOC beds attributable to the NHS Mean
Dark green: England DTOC beds attributable to social care Mean
Light green: England DTOC beds attributable to both NHS and social care Mean

Keeping patients in hospital longer than required can have long term detrimental effects on the individual and their families, and can place additional strain on health and social care resources.

Prolonged stays can affect patient morale, mobility, and increase the risk of hospital-acquired infections. Effects on mobility can be particularly felt by older patients. For every 10 days of bed rest in hospital, the equivalent of 10 years of muscle ageing occurs in people over 80 years old, and building this muscle strength back up takes twice as long as it does to deteriorate. As well as leading to a detrimental loss of independence, this can also mean that patients may require additional health and social care support as a result.

Delayed transfers of care are costly for hospital trusts. In addition to having to pay to provide places for patients who are ready to leave, there are then insufficient beds for people who need hospital care. Delayed transfers can also be costly for local authorities. The longer an older person stays in hospital, the more dependent on longer term social care services they are likely to be when they are discharged.

All councils are committed to reducing their delays in hospitals but this has most success when working in close partnership with health colleagues. Delays in transfers of care can either be reported as attributable to social care (local authority) or to health or to both. Places with higher delays for social care reasons are also more likely to also have higher delays for NHS reasons. Issues within the local health and social care economy as a whole affect the level of delays and so the focus ought to be on the performance of the whole system rather than individual organisations within it.

DTOC Beds per 100000 aged 18+ across NHS and social care by local authority area September 2017
DTOC Beds per 100,000 aged 18+ across NHS and social care by local authority area September 2017

 

Blue: DTOC bedss attributable to the NHS, per 100,000 aged 18+
Orange: DTOC beds attributable to social care, per 100,000 aged 18+

Although delays for social care reasons have increased over the past 12 months, the majority of delays – 56 per cent in August 2017 – are still due to waits for further NHS services. The fact that most hospitals no longer ‘fine’ councils for delays suggests a recognition that this is shared problem requiring collaboration not blame. Holding councils culpable for all delayed transfers is therefore inaccurate, inappropriate and unhelpful. However, the problem still remains and needs to be addressed. There is no single or simple national explanation for the variations and local leaders need to work together to understand what drives local performance and to agree what action will be effective in reducing delays.

Efforts made by the Government to reduce the number of delayed transfers of care focus largely around the use of the Better Care Fund, a pooled budget between local authorities and the NHS to better integrate health and social care services. Local care and health systems are committed to minimising unnecessary hospital stays and providing the best social care support for people who need it.

NHS England provides a monthly summary for England as a whole, by NHS provider and by local authority. This is published approximately six weeks after the end of the reference month. So for example delayed transfers of care in September 2017 were published in November 2017. It includes all ‘bed days’ when a patient is ready to move on from hospital and is still occupying a bed, for all patients delayed within the month. The delayed transfer of care is then categorised by:

  • the type of care the patient receives – acute or non-acute
  • the organisation responsible for the delay – this can be either the NHS, social care or both; for example, if the patient is awaiting a NHS continuing healthcare assessment, then the NHS is the responsible organisation
  • the reason that the patient in question is experiencing a delayed transfer of care; for example, the patient is awaiting a nursing home placement or availability.

NHS providers include organisation that provide NHS treatment or care, such as an NHS acute trust, mental health trust, community provider, or an independent sector organisation. The local authority is the usual residence of the patient delayed. Data for this collection is available back to August 2010.

NHS Trusts, NHS Foundation Trusts and Social Enterprises submit data monthly to NHS England’s online tool for collecting and sharing NHS performance data. The purpose of the return is to identify patients who are in the wrong care setting for their current level of need and it includes patients waiting for external transfer in all NHS settings, irrespective of who is responsible for the delay. Information about delayed transfers of care is collected for acute and non-acute patients, including mental health and community patients.

Data are submitted against each of the 152 local authorities with social services responsibility in which each delayed patient resides. Once data are submitted and signed-off, NHS England performs central validation checks to ensure good data quality.

Figures on delayed transfers of care must be agreed with the directors of Adult Social Services (DASSes). NHS bodies will need to have a secure and responsive system with local care and support partners, which will enable these figures to be agreed by an appropriate person acting in the authority of the Director of Adult Social Services within the necessary timescale for returning data. The President of ADASS has written to DASSs to advise them to ensure that this local verification process is in place and used.

The NHS England 2017/18 Mandate between the Government and NHS England set the expectation that delayed transfers of care (NHS, adult social care and jointly attributable combined) should be reduced by September 2017 to 3.5 per cent of occupied hospital beds, or expressed from a local authority perspective, not more than 9.4 people in total delayed in hospital per 100,000 adults. The NHS calculates this reduction will free up around 2,500 beds per day to help improve A&E performance and help reduce winter pressures. The Government has stated that responsibility for the overall reduction in DTOC should be equal (i.e. 50:50) between the NHS and local government. This equates to reducing delays to release around 1,250 hospital beds by each of the NHS and local government.

February 2017 was the highest ever reported level of delayed transfers of care and was used as the baseline for setting national and local expectations. Overall the reductions at a national level mean that for each sector:

  • reducing from 5.6 people delayed in hospital per 100,000 adults due to social care to approximately 2.6.
  • reducing from 8.5 people delayed in hospital per 100,000 adults due to the NHS to approximately 5.5.
  • whilst also maintaining or improving the current levels of people delayed in hospital per 100,000 adults jointly attributable at 1.2.

This means that adult social care has a disproportionately higher responsibility for reducing DTOCs.

Through the Better Care Fund programme, health and wellbeing boards were asked to agree targets for overall, NHS and social care delays to collectively meet the national levels set. This was a new and unanticipated requirement which was imposed after many areas had already set DTOC targets within their Better Care Fund plan. The methodology applied for delays attributable to adult social care targets was as follows.

  • the best performing local authorities that are already performing below a rate of 2.6 per 100,000 adults on adult social care delays must maintain or improve on this ‘current’ (February 2017) performance
  • the middle performing local authorities that have a rate of social care delays between 2.6 and 7.7 must reduce this rate down to 2.6; this requires the most challenged performer in this group to reduce their rate by two thirds
  • the most challenged local authorities, i.e. those with a rate above 7.7, must reduce their rate by two thirds to achieve the level of reduction required of the most challenged performer in the middle performing group above i.e. reducing their rate by two thirds.

No. At a population based rate, for delays attributable to the NHS within each local authority area the required improvement is defined as follows.

  • in the best performing areas where NHS attributable DTOC are already below a rate of 5.5 per 100,000 adults, the NHS must maintain or improve on this ‘current’ (February 2017) performance
  • in the middle performing areas where NHS attributable DTOC are at a rate of between 5.5 and 11.2 the NHS must reduce this to 5.5 or below; this requires the most challenged performer in this group to reduce their rate by half
  • in the most challenged areas where NHS attributable DTOC are above 11.2, the NHS must reduce their rate by half.

A small proportion of delays are jointly attributable to both the NHS and social care. Levels of jointly attributable DTOC locally and nationally are expected, at a minimum, to be held at their current levels, and where possible improved.

At a local level the share of reduction that is needed across adult social care and the NHS varies reflecting the existing share of delayed days locally. If local NHS and authority partners consider that the indicative split for their area is not appropriate, they may agree a different split.

Appendix 1: DTOC expectations for councils details the expectations set for all Health and Wellbeing Board areas alongside the rate of DTOCs as published for February 2017 which was used as the baseline. Delayed transfers of care are shown as average daily beds (DTOC beds) per 100,000 population aged 18 and over.

Council level data for delayed transfers of care is published monthly – usually on the second Thursday of the month. This report hosted in LG Inform provides a simple overview for your council.

Download further reports.

The LGA is continuing to work with councils and the sector to identify the challenges and barriers and work towards positive solutions that maintain a focus on the people that use the services.

The Care and Health Improvement Programme (CHIP) has in place a support offer and is working to ensure it is well targeted and meets specific local needs on winter preparedness. The key elements of its extended offer on delayed transfers of care comprise:

  • Getting reliable weekly data on DTOC from health and social care to provide a more timely picture at local and national level.
  • A shared view of the true picture - shared across health and ASC – to understand where support is most effectively targeted.
  • Getting the right support into local systems - and significantly increasing the capacity of CHIP to provide timely and appropriate support.
  • A universal support offer to health and care systems on winter preparedness including advice to the sector on resilience, what good looks like and scenario planning.
  • Building a library of case studies to illustrate effective action on DTOC and publishing research and analysis on what works.

Download

Managing transfers of care frequently asked questions 
Appendix 1: DTOC expectations for councils
Appendix 2: About the delayed transfers of care measures
Appendix 3: Understanding and making use of the data available