We need to look at DTOC through a new lens

It’s rather a boring month when we look at the latest figures from NHS England on Delayed Transfers of Care (DTOC) from hospitals. Between May and June, overall delays rose by 0.02%.  Delays attributable to local authority departments of social care were up by 0.04%, and delays attributable to the NHS were down by 0.07%.

Progress seems to have stalled; the question then is why? While there are a number of factors at play, it could be that the incessant focus on the government’s DTOC target is actually part of the problem.

It has led us to looking at numbers (and how we record them), processes (and how we improve them), capacity (and how we increase it) and sometimes at relationships across health and care and how the two sectors can work better together.  None of these lines of enquiry are bad things, but the urgency placed on improvement and crisis of overstretched hospitals during the winter months may have resulted in a lack of focus on the actual causes of delayed transfers.

If we look in more detail at the month of June, we can see that:

• 46% of all delays were due to patients awaiting a long-term care package (either at their own home or in a residential or nursing home)
• 11% of all delays were due to patients awaiting assessment
• 13% of all delays were due to patient or family choice

This means that 70% of the delayed days are associated with waiting for a health or a social care assessment in hospital, or with prescribed support following an assessment in hospital.

In eight local authority areas, and for 36 NHS organisations, this figure is higher than 90%.  This is surprising given the recent emphasis (via increasing evidence and clear legislative guidance) given to not assessing patients in hospital. The alternative is to focus on safe discharge to an environment more conducive to recovery and more likely to maximise outcomes for an individual.

A recent and very helpful guide on the Care Act and DTOC  (published by the Social Care Institute for Excellence) reminds us that ‘decisions on long-term care should not be made in an acute setting’ and that ‘acute trust staff need to be able to describe functional needs rather than stating what service or placement a person requires.’

It also talks about the Discharge to Assess model which ‘is one way of way ensuring that timely assessments are not happening in an acute setting’.  Patients need to be discharged from hospital into a more appropriate care setting where ‘with a stay of up to six weeks, patients receive specialist treatment, support and assessment, with the aim of enabling them to return home or move to a more suitable care setting.’

Delays in hospital typically result in further deterioration of patients’ health and independence, with each additional day spent in hospital increasing the need for both short and long-term support.   There is also an increasing body of evidence including our case reviews which suggests that assessments in hospital result in packages of care that are either unnecessary or higher cost. People’s needs are usually elevated during and directly after a period of ill health, so it is better to assess them fully when they are stable (or after a period of reablement where appropriate).

There is a need to get beyond ‘freeing up a bed’ just to help hit a target to thinking about how the ongoing care needs of an individual can be met in an alternative setting – thus supporting immediate recovery prior to making any assessment of long-term needs.  This is shared cultural challenge (across both health and adult social care services) but addressing it is critical both to achieving DTOC targets and to delivering better outcomes for less.

To see how your local authority is performing on DTOC, or to look at DTOC days and emergency admissions in your local health Trust, download the IMPOWER index.