Are delayed transfers a growing problem?

Comments: 5

Delayed transfers, where patients are ready to return home or transfer to another form of care but still occupy a bed, are a symptom of a system failing to provide the right care, in the right place, at the right time.

Thankfully, the long-term trend in delayed transfers of care has been reducing. Official statistics show that in 2008 on average just under 5,330 patients per day faced a delay in any one month. By 2012, this had dropped to just under 3,990 – a decrease of 5 per cent compared to the year before.

Delayed discharges: Patients and days delayed

However, many of the NHS finance directors we surveyed last December for our quarterly monitoring report said that delayed transfers of care were a key concern for their organisation. Asked directly if delays had got worse over the last year, 63 per cent said they had.

So what might explain this contrast between the official statistics on patient delays and finance directors' views?

Delayed discharges: Patients and days delayed

One answer could be that our survey is not representative of finance directors as a whole. Yet complementing our survey is one from the NHS Confederation which found that, of the chief executives and chairs who reported an impact on their services over the last year due to a shortfall in local authority spending, 92 per cent reported an increase in delayed discharges from hospital.

It would appear that, representative of the whole service or not, these surveys are picking up some concern on this particular issue.

Another explanation for the fact that the service-level view of delayed transfers doesn’t correspond to the official statistics is that the official statistics don’t take into account regional variation. National figures can mask wide variation at local levels. For example, a Health Service Journal analysis of Department of Health data on delayed transfers found that half of all delays were recorded in a quarter of local authority areas.

Furthermore, 12 local authority areas (out of 154) had rates of delayed days more than double the national median.

More interpretation of the data is required, but we are not helped by the way in which the data is collected. There are two main metrics in the official delayed transfers data: the number of patients delayed and the total number of days delayed.  But these two metrics are measured using different methodologies.

The number of patients delayed is counted using a census on the last Thursday of every month – meaning it only counts patients delayed at that one point in time – whereas the number of delayed days is a total of all days that patients were delayed in the month, including patients that were not counted in the census.

It would be more useful to have a record of the number of delayed days for each patient across the whole month. This data is likely to be collected locally and producing these numbers nationally would allow us to see where bottlenecks are (in which regions and where in the system). The numbers could also be used for regional profiling, benchmarking and highlighting best practice.

We also don't know which patients are facing delays in their care but, again, this would be useful information to have. More information on the patients' characteristics, such as their age and details of their conditions and intended management of care would help us identify what needs are not being met. 

With hospitals facing increasing pressure on beds and a fresh focus on quality of services – while purse strings are tightened even further – it seems certain that delayed discharges will remain an important issue facing hospitals. 

Our quarterly monitoring report calls for further investigation into the dissonance between the official statistics and the views of finance directors. Until we can add more insight and evidence, it's likely the disparity – not to mention pressure on the system – will remain.

Comments

#40051 Stephanie de la...
Chair
Business boosters network CIC

The more worrying issues are now that companies such as Arriva plc are now gaining NHS contracts for non Emergancy transfers by undercutting tenders. Their Cqc report is very poor on patient care and even issues with communications, the latest win for them is Sheffield and Manchester and the back lash is now in the media. The need to reduce 20 bil for the NhS is now seeing more of these quality care reductions and can only become more apparent. The health minister may well say that the NhS has to make sure patient care and quality must not be compromised but the reality is that commissoners are hell bent at reducing the bottom line on the accounts. This when we have not yet even had the transfer to CCGs and well being boards

#40053 Sarah Pickup
President ADASS
ADASS/Hertfordshire CC

I think one of the issues may be about perceptions of delays. the pressure on acute beds is such that there is an urgency to move people out and presumptions are often made about who should be responsible and social care is often asked to help or take responsibility even when the official definition woudl not count. With people deemed ready for discharge ever earlier, their level of needs at that point is higher and more complex services are needed to safely get them home- these can take time to arrange. It is often also the case that people arranging their own care and taking time to make choices, people whose homes need adaptation, people who need a CHC/FNC assessment are all perceived as " waiting for social care". It is alsoi the case that no-one ever mentions the changes in the volume sof requests to social care for support nor who is discharged and what is achieved... the counting is all about the delays. We need to stop the blame game and get everyone working to ensure people have the rigt acre in the right place at the right time and we use our joint public funds to best effect to achieve this.

#40070 Gaurish Chawla
@keen_student

Some interesting points have been made above. What we also need to do is to look at how each of the trusts is trying to deal with this problem, and share the lessons. For example, Huddersfield and Calderdale NHS Foundation Trust implemented a Lean programme in the trust to tackle a few problems, one of which was delayed discharges. Their service improvement officer Tania King has reported massive reductions in delayed discharges. I believe there is a lot we can all learn from their example.
Below is a link to a presentation by her, where she describes how they achieved their objectives.

leanuk.org/pages/event_summit_2011_speaker_king.htm

PS I am not affiliated to the trust or the lean enterprise academy.

#40155 Trevor

By keeping people in hospital once their acute needs are met, both health and social care are doing patients a big disservice - because they physically decompensate and are at all sorts of risks (reduced mobility, falls, infection) as a result.

This is a story as much about NHS community services, and how commissioning fails to encourage them to pull patients out of hospital in a timely manner, as about social care's response. However, lets not pretend that the government's 28% cut in local authority budgets does not place restrictions on social services assessment and support package capability to NHS patients. Surely ADASS should highlight this.

Looking at an area by area breakdown of the offical DTOC figures illustrates how inconsistently they are reported. I suspect though that ministers never want this properly investigated for fear of what an even bigger problem they will find.

#40168 Shireen
Manager
Mental Health NHS Trust

With the on-going decommissioning of beds in Mental Health ' to decrease the estate foot-print within Trusts rather than staffing and to offer up cost savings to Whitehall', as mentioned above, more and more patients are being discharged earlier to unsafe and poorly equipped 'recovery houses', local hotels and hostels. They are more more often than not under-treated and with limited community care follow up due to serious understaffing. DTOC meetings are tense affairs. Housing stock is limited, the bureaucracy of endless funding panels, poor quality private accomodation as in residential or supported accomodation contribute to a dismal, revolving door situation. The statistics might show a reduction in DTOC, but it would be useful to get the figures for the rates of re-admission.

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