Got the DTOC letter? Our advice

The letters that are being sent from Sajid Javid and Jeremy Hunt around unacceptable DTOC performance are causing some considerable unrest across the country (indeed they were the talking point of the NCAS conference last week).   If you’ve received one, or are grappling with the issue of DTOC, here are IMPOWER’s seven pieces of advice.

1. Keep calm.  The letters are a blunt instrument with an understandable (if misguided) overwhelming political force behind them.  The media’s attacks on DTOC are creating the weather, and it is reminiscent of the approach to four hour A&E targets and 18 week targets in the NHS: the desired impact is as significant, but over a much shorter time period.  Times are difficult politically and operationally, and the goalposts are changing – the £2 billion is being much more firmly linked to DTOC. This is a massive challenge when, in our sample of £100 million of plans, only 20% of spend is directly attributable.
2. Take another breath and focus on the desired goal.   Hospital is not a good place to be for the majority of your citizens. The NAO report in 2016 estimated that older people lose 5% of muscle mass per day in a hospital bed, which in itself has a whole range of implications for demand on local authority services.  These are real people whose ability to live independently is being jeopardised.  Real people who stayed in hospital over 2 million days more than they needed to, as a result of both NHS and social care delays in the last 12 months (and that is before we even start to look at admissions that could be avoided).  We can do better.  How much of your 2018/19 iBCF plans will demonstrate your ability to address this?
3. Take a step back and ask some questions.  What’s happening locally on your watch?  What are the key issues?  Who’s involved?  What has been achieved so far?  What is the plan?  Do you understand what impact the things you are doing will have? What are the barriers?  Who is accountable?  Where is the governance?   You won’t be doing nothing – from our sample we have over 250 schemes which directly and indirectly impact on DTOC.
4. Re-frame the problem.  You might well be feeling that you are too far down the food chain and have a swathe of demand coming at you – and now you’re being beaten over the head to solve the ‘wicked issue’ that is DTOC.  Reverse the downward spiral, extend the boundaries and think about the issue from a system perspective.  Numbers tell a compelling story: the NAO estimated that DTOC costs the NHS alone some £820 million a year, with an estimated £120 million of additional social care spend required to address this.  At IMPOWER we recently mapped the cohort of individual patients who both came into hospital and accessed social care services at the point of discharge, and found that eight of the top ten diagnoses had an avoidable element (e.g. falls, confusion, UTIs) and accounted for 15% of both hospital and social care spend.  Our system lens shines a light on opportunities at the interface of health and social care that we are blind to.
5. Work together.  Don’t make the mistake of thinking the NHS is sitting pretty and pointing fingers at social care. The NHS’s delayed days aren’t reducing at a national level either and the naughty step is full to bursting.   Self-preservation is an easy state of mind to fall into at the point of crisis, but avoid it at all costs.  System thinking has to extend to system working – which isn’t about an entirely new solution.  In fact, there are times where trust and understanding across organisations and services can have a measurable impact.
6. Look, Listen, Learn.  The ‘not invented here’ mindset should be removed from every corner and replaced by one of ‘discovery’.  There are examples galore of different solutions and approaches and it may be that some of the things you are already doing can simply be tweaked to improve the position.  There isn’t a single solution, and certainly no silver bullet – pride yourself on stealing the best bits from around the country to create that ‘clumsy solution’ – and make sure everyone understands what we expect the impact of each individual component of the solution to be.
7. Demand Results.   Targets and outcomes need to be defined differently to reflect the complex nature of the system and those partners involved.  We can’t and indeed shouldn’t ignore ‘Delayed Days’ or ‘% Delays’ or ‘DTOC Beds’, but there are some more sophisticated measures that will help local systems to predict and monitor success.

Worried because you’ve had the letter, so inspection is next?  Our advice is to use the inspection process to add to the steps articulated above. Work with the CQC to identify the Key Lines of Enquiry that will create the momentum for change, and the understanding of what needs to happen.  Then drive delivery of the results hard and fast – that’s what makes the difference.  And if you have no letter – or indeed you have a letter congratulating you on your performance – don’t rest on your laurels; it’s good practice that will keep you on track.

Do get in touch if you would like to discuss any of this in greater detail, or to learn more about IMPOWER’s current work with some of the councils directly affected by the letter.