This year has been one of the most challenging years for the NHS. The unrelenting pressures on health and social care services have resulted in performance continuing to slip in a number of areas, including A&E performance, waiting times and mental health standards. Yet despite this turbulent time, the collaborative system-wide efforts of both the NHS and social care have resulted in considerable progress being made in one particular area - delayed transfers of care or ‘DTOCs’ as they are often called.
What are DTOCs and why are they a concern?
Delayed transfers of care occur when patients who are ready to be discharged or transferred to another care setting are unable to do so. They can occur in a number of different care settings, including where patients are awaiting discharge from hospital or where they are awaiting a home based care package following a residential or nursing home placement. The delays can cause great distress and uncertainty for patients and their families, as well as putting other parts of the system under increased strain due to reductions in capacity.
In 2016/17, DTOCs soared to a record high and over the course of the year, there were over 2.25 million delayed days across the NHS and social care – 445,000 or 25% more than observed in 2015/16.
In 2016/17, DTOCs soared to a record high and over the course of the year, there were over 2.25 million delayed days across the NHS and social care – 445,000 or 25% more than observed in 2015/16. Reducing these delays for patients became a top priority for the government, prompting the Department of Health to use its mandate to NHS England in 2017/18 to bring down the rate of DTOCs to below 3.5%[1] as a key pillar of the NHS’s winter plan. Efforts were supported by an additional £1billion to support joined up services for the NHS and social care through the Improved Better Care Fund.
2017/18 trends in DTOCs
Since the government target for reducing DTOCs was introduced, there has been a marked reduction in the number of beds occupied by delayed patients. This reflects the whole system commitment by the NHS and local authorities to improve the flow of patients and alleviate demand pressures. The end of year data for 2017/18 shows that the number of delayed days is now down to 1.98million, heading back towards the levels observed in 2015/16. In fact, more than two thirds of NHS trusts and local authorities have reduced the number of delayed days over the past year which demonstrates that local systems nationwide are working together successfully.
More than two thirds of NHS trusts and local authorities have reduced the number of delayed days over the past year which demonstrates that local systems nationwide are working together successfully.
There are now fewer than 5,000 beds occupied by delayed patients each day, down from more than 6,660 in February 2017. This means that across England, 1,600 more beds have been made available daily for new patients. Freeing up these beds is critical for releasing capacity in the system, as well as making sure that people are treated in the most appropriate setting that will help improve their health outcomes.
Not only have we seen fewer beds occupied by delayed patients in 2017/18, we have also seen recent improvements in the overall DTOC rate. Although trusts in England have not reduced the DTOC rate to the government’s target of 3.5%, the overall direction of travel has been positive and in quarter 3 2017/18 the rate was down to 4.5%, the lowest it has been in more than two years.
Although trusts in England have not reduced the DTOC rate to the government’s target of 3.5%, the overall direction of travel has been positive.
This improvement is remarkable considering this year’s winter was one of the most difficult in memory for health services, as a combination of extremely cold temperatures and the worst outbreak of flu in seven years stretched the system to its limits.
The winter period saw bed occupancy levels sustained at above 95%, well above the safe recommended limits, causing a range of adverse knock on effects across the system such as significant ambulance handover delays, lengthy waiting times and the cancellation of many elective operations. If DTOCs had not been tackled this year, the situation could have been far worse.
Who is responsible for DTOCs and what are the reasons for them?
Significant DTOC reductions are evident across both NHS and social care organisations over the last year but the NHS remains responsible for the majority of DTOCs, accounting for 62% of delayed days in March 2018. The most significant decrease over the last year has been observed in the number of DTOCs where social care organisations are responsible for the delay, decreasing by 36% between March 2017 and March 2018, compared to a 13% decline where NHS trusts were responsible.
There are a variety of causes for these delays or ‘bottlenecks’. They can include: an elderly patient awaiting a place in residential or nursing home; a patient awaiting a care package at home so they can be discharged after being treated in hospital for a chronic health condition; or a patient waiting to be transferred from an acute provider to a community or mental health provider.
When looking across the system as a whole, more than a fifth (22%) of DTOCs are due to patients awaiting a care package in their own home. However, the main reasons for delays differ between NHS and social care organisations. In March 2018, almost a third (31%) of DTOCs where the NHS was responsible were as a result of patients awaiting non-acute NHS care. This can be compared to 37% of delays which were caused by patients awaiting a care package in their own home where social care organisations were responsible.
When looking across the system as a whole, more than a fifth (22%) of DTOCs are due to patients awaiting a care package in their own home.
Considering the majority of NHS delays occurred because of issues within the NHS itself, this shows that more needs to be done between NHS organisations to encourage the timely transfer of patient to non-acute care settings.
Top 5 reasons for delays in the NHS and Social care – March 2018
|
NHS |
Social care |
|
Awaiting further non-acute NHS care (31%) |
Awaiting care package in own home (37%) |
|
Patient or family choice (17%) |
Awaiting residential home placement or availability (24%) |
|
Awaiting care package in own home (11%) |
Awaiting nursing home placement or availability (17%) |
|
Awaiting nursing home placement or availability (11%) |
Awaiting completion of assessment (15%) |
|
Awaiting completion of assessment (10%) |
Patient or family choice (3%) |
Is the new DTOC mandate set out in the March 2018 planning guidance achievable?
The latest mandate for the NHS published in March 2018 saw a revision in the target for DTOCs, moving away from the 3.5% DTOC rate target and instead targeting a reduction in the average daily number of beds occupied by delayed patients to fewer than 4,000 by September 2018.
Given that the last time the daily number of DTOCs was below 4,000 was April 2014 and given the current pressures on both the NHS and social care this does seem a tall order. The latest monthly performance data also suggests that whilst daily delays have significantly reduced over the course of the last year, the rate of month on month improvement in quarter 4 2017/18 is stalling. Alongside this challenge trusts are also facing the unprecedented demand increases we have seen this year in A&E attendances, emergency admissions and patient waiting lists.
Figure
We need to be realistic. Demand in the NHS is still rising, and the capacity and resources available to continue the substantial progress trusts have already made on DTOCs over the last year are limited. Having sufficient capacity in the system means that trusts and local authorities have the ability to respond to planned and unplanned events and emergencies, and manage variations in demand.
Demand in the NHS is still rising, and the capacity and resources available to continue the substantial progress trusts have already made on DTOCs over the last year are limited.
The key to further reductions in DTOCs is to continue system wide collaboration and, as we move to a world of integrated care systems, to strengthen local relationships. This is more critical than ever. NHS and local authorities are clearly starting to build these relationships and they have yielded positive results over the last year. Deepening these connections further and developing mechanisms to prevent internal NHS delays will hopefully set DTOCs on a trajectory for further improvement throughout 2018/19.
[1] The DTOC rate is a calculation of the total delayed days out of the total number of occupied beds in a given period.