The rise of delayed transfers of care

- Key points
- Context
- Analysis
- Conclusion

Delayed transfers of care, where patients are ready to go home or be transferred to another setting but are unable to do so, are widely recognised as one of the most significant pressures and risks in the NHS. They are bad for both patients, as they might lead to longer stays than is necessary, and for NHS trusts, as they reduce capacity available across the system to admit, move or discharge patients.

This NHS Providers briefing sets out analysis of what is happening on the ground, and where the increases in delayed transfers of care are occurring.

Key points  

1. Since 2014/15 the number and rate of delayed transfers has been consistently and rapidly rising.
2. Despite current national and local focus on tackling delayed transfers of care (DTOCs), there are few signs of sustainable improvement this financial year (2017/18). There was a decrease in April but the data for May showed no further improvement.
3. Acute providers have the highest number of DTOCs, but the providers with the highest percentage of their beds occupied by DTOCs are in the community sector (peaking at 28.5% in January 2016).
4. Delays due to social care are rising faster than delays where the NHS is responsible: since April 2014 NHS delays have increased around 25%, whereas social care delays are up by 130%.
5. In May 2017 there were over three times as many delayed days due to “patients awaiting a care package in their own home” than in April 2014.
6. The NHS has been asked to bring down the DTOC level to 3.5%, but the sector has not achieved this since the first quarter of 2014/15, we need to be realistic about how quickly performance can be recovered.
7. Efforts to tackle the problem of DTOCs need to take a whole-system approach. This is in line with the views of frontline leaders in our recent report that there is a lack of capacity across all parts of the system.

Context

The pressure delayed transfers cause across the health and social care system is intensifying. While there has been some recovery over the first two months of 2017/18; almost every time NHS England releases the next round of data, DTOCs have reached record levels (again). In 2016/17, there were 2.3 million delayed days, or 6,200 per day. That equates to 11 averaged sized hospitals (defined as having 550 beds) being full every day with patients who could be better cared for in another setting.

What is particularly concerning is that the scale of the problem might be under-reported at the national level. Delayed transfers of care are very specifically defined and recorded. NHS England defines patients as ready for transfer when:

1. A clinical decision has been made that patient is ready for transfer AND
2. A multi-disciplinary team decision has been made that a patient is ready for transfer AND
3. The patient is safe to discharge/transfer.

Research reported by the Nuffield Trust found that in some trusts the number of patients who were ‘medically fit for discharge’ could be more than three times the number declared as DTOCs, in the NHS England definition.

The challenges this poses for the health system are well recognised, and there has been a welcome national focus on supporting local areas to reduce DTOCs, helped by the additional £1bn investment made in social care this year (though it is unclear at this stage how much of this funding will go towards purchasing extra packages of care that help relieve pressure on NHS services). However, any national response needs to be guided by what the data tells us about where the problem is occurring and how it is manifesting itself in different parts of the NHS. 

Analysis

We can look at the DTOC data in two ways:

• one is to look at the total number of days a bed was occupied by a patient with a DTOC (total delayed days)
• the other is the percentage of all occupied beds that are occupied by a patient who is delayed (the DTOC rate). The government has set NHS England the task of reducing the DTOC rate to 3.5% by September this year.

How fast are delayed transfers of care increasing?

Delayed transfers of care, between the NHS and social care and between NHS organisations, is a longstanding issue.

However, the scale of the problem has escalated over the last three years. In quarter 1 of 2014/15 there were 367,000 delayed days, but by quarter 4 of 2016/17 this had reached over 580,000, an increase of almost 60% (figure 1). Over the same period the DTOC rate has increased from 3.5% to 5.6% (figure 2).

Are all sectors facing the same problem?

National and media focus on DTOCs tends to highlight delays in the acute hospital sector (e.g. BBC News, Independent, Guardian) and if we look at the total delayed days by sector we can see that the highest number of delays happen in hospitals (figure 3). In March 2017 the acute hospital sector had over 140,000 delayed days, compared to around 6,900 in community trusts.

However, acute providers make up almost 60% of the NHS secondary care provider sector, and have over 80% of all beds, so we would expect them to have the highest number of delays. The fact that the acute sector has the highest number of delayed days is a simple illustration of the fact that the sector has the largest number of beds.

If instead we look at the DTOC rate by sector we can see a different picture emerging, with community providers much more significantly affected by DTOCs (figure 4). This peaked in January 2016 when on average 28.5% of beds in community providers were occupied by DTOCs, compared to 4% for acute providers in the same month.

What are the reasons for the delays?

NHS England breaks down the DTOC data in three ways:

• by type of care (acute/non-acute)
• by sector (NHS or social care)
• by reason for delay

Indexing the total delayed days data allows us to look at the rate of change in each of these areas from a particular starting date, in this instance April 2014 when the DTOC rise started in earnest.

1. By the type of care the patient was receiving:

The data shows that since April 2014 total delayed days for patients receiving care in acute settings (for example in hospital) has increased slightly faster than for patients receiving care in non-acute settings (for example community care), but the difference is small (figure 5).

2. By the organisation responsible for the delay:

When we look at the responsible organisation we can see that over the past three years while the total number of delayed days has increased by 1.5 times (or over 50%), delays attributable to the NHS have increased around 25%, and delays attributable to social care by 130% (figure 6).

3. By the reason for the delay:

NHS England gives a list of 10 reasons for a DTOC. There are two reasons that are clearly rising faster than the others: ‘awaiting care package in own home’ and ‘awaiting nursing home placement or availability’ (figure 7). In May 2017 there were over three times as many delayed days due to patients awaiting a care package in their own home compared to April 2014.

Conclusion

The scale of the problem caused by DTOCs is severe and widespread, and we need to be realistic about how quickly performance can be recovered. The NHS has been asked to bring down the DTOC level to 3.5%, but the sector has not achieved this since the first quarter of 2014/15. While there is some evidence that the tide is starting to turn, supported by the additional £1bn investment made in social care this year, there is still a long way to go.

This analysis has highlighted the importance of taking a whole-system approach to tackling DTOCs, recognising the significant challenge for community and mental health providers and the interdependence with social care for an effective resolution.

Too often, the national level has focused on capacity issues in acute hospitals but the scale of the challenge is now too large, and potential solutions too complex, to deal with issues in isolation. Efforts to tackle DTOCs will only be effective and sustainable if we focus equally on ambulance, acute, community and mental health capacity, along with primary and social care capacity.

The pressures identified in this briefing are symptomatic of the wider challenges facing health and social care services, as growing demand outstrips capacity. In our recent report Winter warning: managing risk in health and care this winter, frontline leaders reported a lack of capacity across all parts of the system to deal with the expected demand this winter. This means that efforts focused on tackling DTOCs will do little to alleviate the pressures facing the NHS unless a whole-system approach is taken.

Read our analysis of how hospitals performed over winter.