What are delayed transfers of care?
According to NHS England, a ‘delayed transfer of care’ occurs when an adult inpatient in hospital (children are excluded from this definition) is ready to go home or move to a less acute stage of care but is prevented from doing so. Sometimes referred to in the media as ‘bed-blocking’, delayed transfers of care are a problem for the NHS as they reduce the number of beds available to other patients who need them, as well as causing unnecessarily long stays in hospital for patients.
Delays can occur when patients are being discharged home or to a supported care facility such as a residential or nursing home, or require further, less intensive care and are awaiting transfer to a community hospital or hospice.
NHS England, the body responsible for monitoring delayed transfers of care nationally, defines a patient as being ready for transfer when:
- a clinical decision has been made that the patient is ready for transfer, and
- a multidisciplinary team has decided that the patient is ready for transfer, and
- the patient is safe to discharge/transfer.
As soon as an adult patient meets these three conditions and remains in hospital, the clock starts and they are classified as ‘a delayed transfer’. All hospitals are required to collect this data and provide it to NHS England.
Why do delayed transfers of care occur?
Patients can often be delayed waiting for onwards care, for example at a community NHS facility such as a community hospital. They can also be delayed by 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 acute 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 difficult process.
Other factors can also come into play. These include 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.
What is the impact of delayed transfers of care on the wider health system?
Delayed transfers of care are a significant concern to frontline staff. Once a patient is well enough to leave hospital, staff want to treat other patients with greater needs.
There are also potential effects on the patient. Longer stays in hospital are associated with increased risk of infection, low mood and reduced motivation, which can affect a patient’s health after they’ve been discharged and increase their odds of re-admission. The National Audit of Intermediate Care shows that, for older patients, ‘a wait of more than two days negates the additional benefit of intermediate care, and seven days is associated with a 10 per cent decline in muscle strength’.
There are also financial consequences. There is a wasted investment in unnecessary care for every day that a patient is kept in hospital longer than necessary. These patients won’t need intensive treatment or the same amount of equipment or medicine as before, but they still cost the hospital staff time and space that should be used for something else. Delayed transfers of care are consistently one of the top three concerns expressed by NHS finance directors surveyed in our quarterly monitoring report.
More indirect effects come from how delays can affect the flow of patients through a hospital. For years now, the NHS has been reducing the number of hospital beds as the average length of stay in hospital has continued to decrease. Admissions have kept rising though, so the bed capacity of the average hospital in England is close to being completely full.
With admissions up and beds down, hospitals need to keep stays short, so they can move on to the next admission quickly. When a hospital is close to capacity and suddenly suffers a series of delays, there is nowhere for new admissions to go, with consequences for waiting times.
How are delayed transfers of care measured?
NHS England publishes two measures: the number of patients still delayed at midnight on the last Thursday of the month, and the total number of bed days taken up by all delayed patients across the whole calendar month.
Some transfers, however, are not included in these figures, such as transfers of child patients and patients within acute care (for example, being moved from a cardiology ward to a fracture ward).
What are the limitations of this data?
The data on delayed transfers of care has the benefit of being agreed between NHS and social care providers. This means that we have an agreed number of delayed transfers across the health and social care system, giving us some indication of the true size of the problem.
However, there are limitations to the data.
It is not clear whether all providers are using the definitions of delayed transfers of care or reasons for delay in the same way; small differences in interpretations could lead to large changes in reported numbers.
The count of patient delays – a snapshot taken on the last Thursday of each month – is also questionable as a measure. Counting patients at midnight on one evening per month will hide lots of variation within the month. A better measure might be to measure the total number of patients delayed each month. If the information is there to count the total number of delayed days each month it seems reasonable that the total number of patients could be counted.
The data on delayed transfers of care is further split into acute and non-acute delays, but this definition is unique to this dataset (it is based on the care the patient was receiving, not the organisation where the care was delivered). It is not clear why this definition is used solely here, but it can lead to misinterpretation of the data.