The problem of DTOC has basically been addressed, but the problem of demand most certainly has not
We have recently been working with a local council where discharges from local hospitals are placing increased pressure on their already-stretched social care budget. Despite a genuine commitment to address the problem, there is no marked improvement.
From our experience, there are seven steps that would help resolve the situation.
- Recognise that Delayed Transfers of Care (DTOC) are a distributed problem. Leaders from both the NHS and the local authorities’ Adult Social Care Departments need to recognise each other’s biggest issues when it comes to DTOC. For councils, it is the cost and pressure on long term care placements; and for the NHS, it is the over-reliance on the acute part of the health system. The next step is for both sides to widen the lens. Both issues can be addressed if they are recognised as equally important to whole system outcomes.
- Proper use of BCF/iBCF. The use of internal pots and creative accounting needs to stop. Both sides need to agree one decision-making route for strategic funding decisions across each health and care economy. BCF money should be used to create a joint intermediate care offer from hospitals – one that helps keep people out of hospital in the first place.
- Reduce reliance on long-term care placements. Systems need to be re-drawn to prevent placing patients straight from hospital into long-term care packages, especially residential and nursing care. In 2016/17, 13% of all new requests following discharge from hospital went straight into long-term care – and in some areas the figure was as high as 25%. These numbers are simply unsustainable. Change is required at the front line, in order to replace staff behaviours that encourage dependency with those that promote independence.
- Create the right capacity. Once freed up by the creation of a genuine pooled budget with a clear remit, commissioners need to procure and coordinate the right set of alternative short-term interventions that support and underpin step up/step down services in the community. Only then can a genuine discharge to assess (D2A) offer be put in place.
- Apply the Discharge to Assess model. Once their commissioners have provided them with a suite of local short terms interventions (from emergency domiciliary care, reablement and rehabilitation right through to supporting voluntary, community and social enterprise organisations), joint triage teams need to create community pull from both ends of the hospital. They need the right kinds of flexible and fast supply to be available in the community. Full social work assessments need to be moved back into community settings where they can be most effective in building strengths-based support plans.
- Focus on the Front Door. Hospital admissions must be avoided in the first place. A recent review of patient case notes in an acute hospital for 107 short-stay non-elective admissions was revealing. Almost two-thirds (63%) of the admissions were not clinically driven, and more than one-third (35%) of the patients could have been seen in the community without the need for an A&E attendance or a hospital admission, if sufficient resources had been redirected to community-based care, and appropriate support made available.
- Undertake commissioning in partnership. The way commissioners work with local providers needs to change – and fairly radically. The care market is vulnerable, and if commissioners are to be able to create the right supply for the Discharge to Access model to be effective, they need to be out talking with providers. They need the support of Directors of Adult Social Services to enable them to take some risks.