First, a quick recap. The Spring Budget 2017 provided an extra £2 billion to support adult social care – in part to help tackle steeply rising rates of delayed transfers, but also to support the local social care provider market and meet increasing adult social care needs. Then the Department of Health mandate to NHS England for 2017/18 set an explicit target to reduce delayed transfers to the level where they occupied no more than 3.5 per cent of available NHS bed days1 by September 2017. It was hoped that this would allow the NHS to free up 2,000–3,000 acute hospital beds and improve hospital waiting times. But focusing narrowly on delayed transfers of care led to a damaging row between local authorities and NHS England as it quickly became apparent the target would not be met.
No one would argue with the desire to see fewer and shorter delays in discharging patients from hospital. But to achieve the target would have required the equivalent of cancelling out three years of growth in delayed transfers in five months when health and social care services were under unprecedented pressure. This was never likely to happen.
Now that the dust has settled, what progress has been made? Figure 1 shows that the target was missed by a wide margin, with the proportion of occupied bed days due to delayed transfers remaining above 5 per cent rather than falling to 3.5 per cent. But looking at the data for individual months shows the progress the health and care system has made in reducing delayed transfers this year. The total number of delayed transfers in September 2017 is down 14.4 per cent compared to September last year. Over the past four months average daily delayed transfers have dropped below last year’s levels (Figure 2), moderating the spiralling growth we have seen since 2015.
Both the NHS and social care have played their part in reducing delayed transfers. Figure 3 shows this longer-term trend of growing delayed transfers, together with the organisations responsible for the delays. While the NHS continues to be responsible for the majority of delays, the proportion of delays attributable to social care increased substantially from 29 per cent at the beginning of 2015/16 to 38 per cent at the beginning of 2017/18. But compared to February 2017 – the highwater mark for delayed transfers overall – delays attributable to social care decreased by 16 per cent, and delays attributable to the NHS decreased by 14 per cent by September 2017.
So what lessons can we learn from this? First, targets should focus on the right issues. A recent Care Quality Commission report into health and care systems notes: ‘Focusing on [delayed transfers] in isolation will not resolve the problems that local systems are facing.’ Placing a disproportionate focus on short-term reductions in delayed transfers, can distort the priorities of both health and care organisations that must also address wider and more strategic capacity pressures in the health and social care system. Second, targets should be achievable. The proposed reduction in delayed transfers of care was never likely to be attained and led to divisive recriminations across health and care organisations (both nationally and locally), precisely at a time when health and care services are attempting to collaborate more in partnership. Although the September 2017 target was missed, reversing the rapid recent growth in delayed transfers should be more lauded as the significant achievement it was.
- 1. The target set out in the mandate and Better Care Fund planning guidance was to reduce delayed transfers of care nationally to 3.5 per cent of occupied bed days by September 2017. Unlike other national targets, there is no widely stated definition of how the delayed transfers target was constructed and measured. We have interpreted the target to be the number of delayed transfer days as a proportion of the number of occupied consultant-led bed days. This figure can be calculated over a quarter (as in Figure 1) or a calendar month.
Thanks David, interesting commentary.
On Figure 3 re "responsible organisation", do you have any data for the number of delays that are not due to any organisation, but are because either the patient or the carers / relatives object to the discharge? I regularly had to support my frontline staff when I was a CEO, in cases where patients or relatives didn't want to leave the NHS - for a variety of reasons ranging from very high levels of satisfaction with their care, to not wanting a transfer into self-funded residential care...
Hello Ed, thanks for reading the blog. The data does indeed break down in such a way (though how reliable those definitions are is discussed here: https://www.kingsfund.org.uk/publications/delayed-transfers-care-quick-…), and the number of delays attributed to "Family disputes" is actually very low, the least common reason for delay in 16/17 (see Figure 1 in that link). Whether this is a reporting and data capture issue or a true reflection I'm not sure.
Any dispute with a family or patient is always coded as a health wait because it's not a social care wait (as they have done everything they can & it is left in Health's hands to choose to resolve). It is not Health's fault either but we have no code for 'Other'. The same applies if we need an agency to do a deep clean or if we're waiting on a private housing company. There are other examples. The current DTOC format is getting outdated & we need to come up with an updated version