What are delayed transfers of care?
A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed. Delays can occur when patients are being discharged home or to a supported care facility, such as a residential or nursing home, or are awaiting transfer to a community hospital or hospice.
Delayed transfers – also referred to as ‘DTOCs’ or sometimes, often in the media, described as ‘bed-blocking’ – can cause considerable distress and unnecessarily long stays in hospital for patients. They also affect waiting times for NHS care, as delayed transfers reduce the number of beds available for other patients. Here we look at how delayed transfers of care are measured, why they occur, and what impact they have.
How are delayed transfers of care measured?
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 a patient meets these three conditions and remains in a bed, the ‘clock’ starts and they are classified as ‘a delayed transfer’. The definition of delayed transfers of care used by NHS England is very specific. For example, data on delayed transfers does not include delays in transferring a patient between different wards in the same hospital, or between different hospitals, if the patient still requires acute hospital treatment.
Each month NHS England publishes two measures of delayed transfers.
- The total number of bed days taken up by all delayed patients across the whole calendar month. For example, in October 2017 there were 170,100 total delayed days.
- The average daily number of delayed transfers across the month. Referred to as ‘delayed transfer of care beds’, this measure is calculated by dividing the number of delayed days during the month by the number of calendar days in the month. For example, in October 2017 the 170,100 total delayed days, divided by 31, gives a daily ‘delayed transfer of care beds’ figure of 5,487. This measure replaces previous data (collected until the end of March 2017) on the number of patients still delayed at midnight on the last Thursday of the month.
All hospitals are required to collect delayed transfer data for adults (aged over 18 years) and provide it to NHS England, together with the reasons for these delays.
There are limitations to the national data on delayed transfers of care. It is not clear whether all providers are using the definition 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.
National data may also understate the number of patients who could be cared for safely and effectively out of hospital. This is because the ‘clock’ for measuring delayed transfers only begins when a full multidisciplinary team has assessed the patient’s needs – for example, to determine if a patient needs further therapy or social care input – before deciding when the patient can be discharged. Patients in hospital who have been assessed by a consultant or other clinician as being ‘medically fit for discharge’ will not be counted as a delayed transfer before this fuller assessment takes place.
Why do delayed transfers of care occur?
The proportion of delayed transfers due to social care has risen steeply since 2014, but the majority of delays (58 per cent in 2016/17) are still attributed to the NHS. However, it is too simplistic to view delayed transfers as either a ‘social care’ or ‘NHS’ problem. Delayed transfers can be the result of delayed processes within the NHS, social care, or across both sectors, and can occur for a number of reasons.
Patients can often be delayed waiting for onwards care. For example, intermediate care services occupy an important middle ground between primary and hospital care for patients leaving hospital. These services include bed-based care, rehabilitation and reablement services, which often provide a much-needed ‘step-down’ service for people moving between more intensive hospital care and independent living or social care. However, recent reports suggest there is insufficient capacity to meet the demand for intermediate care, resulting in increased waiting times and delays in accessing this much-needed care.
Agreeing that a patient is fit for discharge, as well as acquiring a care package and getting paperwork completed on time, can also be difficult. Assessments must be made of the additional support and care patients will need after leaving hospital, such as care workers providing support for daily activities, and installing hand rails within patient’s homes to improve their safety and mobility. Delays can arise because a patient’s assessments are not planned and completed before they have recovered sufficiently to be discharged. Completing an early assessment of onward care needs generally requires agreement from a multidisciplinary group of acute clinicians, social workers and other care workers. This can be a time-consuming and complex process.
Other factors can also come into play. These include disagreements 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.
National data on the reasons for delayed transfers of care is collected in several categories (see Figure 1). In 2016/17, delays where the patient was awaiting a care package in their own home accounted for the largest number of delays (more than 20 per cent of all delays).
Why are delayed transfers of care important?
The timing of discharging patients from hospital is important. Sending a patient home from hospital prematurely, before their medical care is completed, can lead to poor patient experience and readmission to hospital. But delayed transfers of care are currently a significant concern to patients and staff in the health and care system. 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 chances of readmission to hospital. The National audit of intermediate care argues that, for older patients, a delay 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 due to long periods of immobility in a hospital bed.
Delayed transfers of care also have a negative impact on the finances and performance of the health and care system. Even though patients delayed in hospital do not require the same intensive level of clinical care, hospitals must still provide staff and resources to care for these patients. Delays in discharging patients also affects 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. However, hospital admissions continue to rise, so the bed occupancy of the average hospital in England continues to exceed recommended levels. When a hospital is close to full capacity delayed transfers can mean there are no beds available for new admissions, with consequences for waiting times in A&E departments and for planned surgery.
Reducing delayed transfers has been a key focus of recent national policies, such as the Better Care Fund (a pooled budget to help councils and NHS organisations to plan and work together to deliver local services). In its 2017/18 mandate to NHS England, the Department of Health set a target for delayed transfers to be reduced to no more than 3.5 per cent of all hospital bed days by September 2017. However, our assessment of delayed transfers suggests this target was missed by a substantial margin.
However, a recent review by the Care Quality Commission noted that focusing on delayed transfers in isolation can divert attention from other important opportunities to deliver better care. Sustainability and transformation partnerships are now exploring a wider range of opportunities for more integrated, collaborative and effective working across health and social care services.
You can read our further analysis of current trends in delayed transfers of care here.
Greetings to our friends at the King's Fund in 2018! The 1980s was the period of the "waiting lists" for community services, and the "lists" in which, we would offer services such as highly valued family support, continue now (2017, aging and caregiving) at the American Association for Retired Persons (AARP). On the nursing facilities and hospitals, "we have" refusals to allow to homes after hospitalization and forced confinement in nursing facilities yet (e.g., placing short-term rehab in a private, old, large place and cutting off personal physician to "treatment decision"). Julie Ann Racino, ASPA, HHSA, 2018