Ben Evans

What I’ve learnt about DTOC (from discussing it over dinner)

May 17, 2018

Being married to a Junior Doctor GP trainee means that I get to experience the health and social care system from two very different perspectives.

DTOC (Delayed Transfers of Care) is where my work and home life intersect the most. Many clients I work with are being beaten with the DTOC stick, but I find the obsession with them to be a bit flat earth. Where is the evidence to suggest that this is the single measure that the entire health and social care system should be judged by?

However, from a medical practitioner’s perspective there are other considerations. For example, my wife’s hospital is so consistently understaffed that having between a quarter and a third of the beds filled with DTOC patients (who require no medical intervention) actually allows staff to keep up with the workload. This is obviously far from ideal, particularly given that the cost of a bed day (£400) is roughly two thirds the cost of Senior House Officer locum day cover.

It is also unreasonable to expect a doctor on a four-month rotation to be knowledgeable about community discharge pathways and the social care offer. By all means embed the knowledge with the consultants and permanent ward nurses, but trying the same with the transient junior doctor population is a zero-sum game.

Thirdly, as the Conservatives found out 12 months ago, there is very little understanding of social care charging among the general population. This means that patients’ relatives will sometimes try to prolong hospital stays for as long as possible once they realise that care costs will hit their inheritance – and there is little that hospital staff can do about it.

A common accusation levelled at medical practitioners is that they are risk averse, which drives system delays and costs, and compromises independence-focused outcomes. I will make two pleas in mitigation. Unlike social care staff, doctors carry a personal liability for their actions and decisions – between 40% and 60% of the fee for an out-of-hours GP locum shift goes on personal liability insurance. Additionally, GPs are expected to deal with everything, so whilst they could (and should) know about community support options near the practice, they also need to be able to identify if that blotch on someone’s skin is a spot, or the first sign of Ebola.

Sitting atop everything is the primacy of acute hospitals within the health and social care economy. As long as alcohol and fireworks remain legal, there will always be a requirement for acute healthcare environments, but a funding model based on patient volumes (coupled with the centrality of acute hospitals) does not support outcome-focused system behaviours. A rebalancing of the role of acutes in proportion to that of primary care and social care needs to take place.

I believe that in the medium to long term, the health and care offer can only be sustainable if it comes under the umbrella of a single governance structure and funding pool. This would help to shift the focus away from acute primacy. A system where all stakeholders have their financial skin in the game – and where the best option is to keep people at home and independent – will hopefully drive different behaviours and resourcing decisions.

Likewise, sustainable outcomes could arguably be best achieved through a combined service with the common objective of keeping people independent and well for as long as possible.

Maybe a single organisation (or umbrella structure) isn’t the right way to achieve this, but history has shown that without structural alignment and shared incentives, it is near impossible to make transformational and lasting change.

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