Delayed Transfers of Care: Coping with the crisis

Patients, social care and health must work together to deliver a sustainable system through demand management.

The issues in managing demand in hospital are well documented and has resulted in significant emphasis in policy and funding in solving the issue.

To tackle the issues within hospital the key performance measure being monitored is through Delayed Transfers of Care (DTOC). National funding is now allocated for social care and with it comes an expectation that this will positively impact on DTOC (using various measures) – there aren’t ‘conditions’ but the message is clear and the CQC are on point to ‘inspect’ where DTOC rates are not improving.  This has created a swathe of panicked activity, causing a potential danger that people perceive the answer to DTOC to simply improve process, or increase capacity (paid for by the non-recurrent £2bn).

So, who believes health and social care will be successful in managing demand in 2017/18? Who believes the additional funding will be used wisely to support delayed transfers of care?

To get a sense of the scale of the problem, statistics published by NHS England recently indicate:

• There were 184,900 delayed transfers in February 2017, 124,000 of which were in acute hospitals;
• Of these delays, 36.4% were attributable to social care, which is a rising statistic when compared to the same period last year;
• Virtually all these delays (over 35%) were attributed to ‘patients awaiting care packages in their own home’.

However, tackling the problem is difficult as the complexity of patient needs are increasing. The requirement for a collaborative approach from health and social care will be a challenge given the difference in culture, approaches and processes, as well as trust and relationship issues.

In both health and social care the need to push people through the hospital system and out into alternative services encourages a range of actions that creates additional demand on services. In our recent work in this area we have identified the following examples where demand is being generated:

• Avoidable demand: limited communication with the patient about what they want, what resources and support they have and where they want to get to. In one area, in a third of cases medical staff had told patients or their families what care they should expect prior to assessment being carried out and nearly all of these cases ended up with nursing or residential care – almost 50% of this was unnecessary;
• Failure demand: a risk averse nature and the desire to ‘fix’ patients is drawing people into hospital, there is little consideration of the risk of ADMITTING to hospital in terms of loss of independence. Through our discharge case reviews 44% of cases were admitted with no social care but left with a package averaging £440 per week;
• Excess demand: Obsession with the clock and discharging into any service or using any pathway which releases a bed. In one area 50% of referrals to re-ablement services at the point of discharge aren’t resulting in any service need;
• Co-dependent demand: Lack of co-ordination of activities between health and social care in managing discharge process resulting in poor outcomes for the patient.

At IMPOWER we believe that core to managing these demand failures is a focus on human factors, managing demand at the interface between health and social care, and providing sustainable out of hospital alternatives.

1.       Create a clear understanding and translation of needs between health and social care

Hospital staff are focused on freeing up beds, meaning patients are pushed into discharge pathways without the need or time to consider the impact of choosing the wrong pathway, or putting in place support that creates unnecessary levels of dependency.

Social care staff focus on maximising independence, recognising the person is at a point of crisis and not reacting by putting in place ‘knee-jerk’ support. This is done by taking time to choose the right pathway, getting the person back home and self-managing as quickly as possible.

For the system to work, behaving in ways that support both ‘flow’ and ‘independence’ are critical – without this there will always be conflict at the interface, with patients suffering as a consequence. That requires a translation between health and social care in terms of approach, language, understanding, processes and communication.

2.       Changing the conversation

In social care, the desire to look after people is ingrained, in health the desire to ‘fix’ people through a medical model is ingrained. However, the world is changing, lifestyle factors mean people are living with co-morbidities and social issues daily. Therefore, there is a need to change our approach to helping people support themselves more rather than creating dependence on formal services. Changing the conversation with patients designed around 3 key questions will help:

1.       How can I help you to help yourself? i.e. ‘Sorry you are in hospital, you’ll be better at home, how can we get you there?’

2.       What resources do you need to help yourself? i.e. ‘When we get you home what will you need to help you manage at home?’

3.       How can we work together? i.e. ‘If you do require further support, how can we work with you to ensure that you get the right support to address your long-term goals?’

This approach empowers and supports patients to co-create their plan to leave hospital with the necessary resources and care package to promote independence, consequently reducing demand on other non-hospital services.

3.       Providing sustainable alternatives outside of hospital

Thinking innovatively but practically in finding alternative approaches to supporting people at home is important. Improved use of technologies both assistive and informative, connecting people into their local communities, and supporting the vast army of carers is vital. Where formal services are required ensuring there is a mature conversation with providers in supporting sustainability whilst incentivising the market to maximise individuals’ independence is important in managing demand.

At IMPOWER we have worked with several Local Authorities in successfully implementing a demand management model with significant reductions in demand and subsequent financial savings, also creating an opportunity for individuals to live more independent lives. We are currently working with select NHS organisations in translating this approach to manage demand in health.