Blog 1 of 2. In this journal entry our expert practitioner Stephen Tucker looks at the DTOC figures to better understand the scope and severity of the issue on patient flow and the need for STPs as a relief valve - but can all trusts afford to wait for STPs to deliver their intended benefits?
In April, it emerged that a patient with complex support needs has been waiting over 3 and a half years to be discharged, having been declared fit to leave hospital. Albeit an extreme example, this highlights that the NHS has a real struggle on it's hands over the issue of Delayed Transfers of Care (DTOCs).
NHS England have just published DTOC data for March 2017 to complete the 2016-17 year, providing a good opportunity to explore the extent of the problem, identify the underlying trends and what this means for the future of the NHS.
At the highest level, DTOCs are on the rise. The number of delayed days (the sum of all daily reported DTOCs) exceeded 500,000 in each quarter of the 2016-17 year, having never reached this level before.
Total DTOC delayed days by quarter: '13/14 – '16/17
The peak of 588,746 delayed days in quarter 3 2016-17 is equivalent to 6,500 NHS beds being taken up by medically and functionally fit patients for the duration of the period, or to put it another way: 13 large hospitals filled with patients, that don’t need to be there, for 3 months.
However, many NHS facilities will tell you it is not just the number of beds being taken up, it is the impact they have on disrupting the flow of patients and the general operation of the hospital.
So what is behind this trend? Comparing DTOCs in the acute and non acute setting reveals that the situation seems to be getting worse, and at a faster rate within the acute setting, as the table below demonstrates:
By going back 3 years and comparing with data from 2016-17, we see that delayed days in the non-acute setting have increased by 41.8%, whereas in the acute setting delayed days have increased by almost 70%.
Of course a 40% increase over 3 years is still a significant challenge within the non-acute setting, but what this data suggests is that the more complex needs of acute patients are compounding the problem.
Many Acute Trusts will acknowledge the increasing strain this is putting on the quality of care services they provide. However, many will go on to talk about the lack of social care availability as the primary reason for the problem. This is a perception often reflected in the media and, unfortunately, is why the term DTOC is often used interchangeably with ‘bed blocking’. Bed blocking is defined as the long-term occupation of hospital beds, chiefly by elderly people, due to a shortage of suitable care elsewhere. But is this what is happening here?
Breaking down the total delayed days by attributable organisation paints an alternative picture:
DTOC delayed days comparison by responsible organisation: '13/14 Vs. '16/17
In 2016/17, 58% of delays are attributable solely to the NHS, compared with only 35% to social care. So why is there a common perception that social care is the biggest contributor to DTOCs? If you instead look at the trend over the past 3 years, then this becomes clearer.
% change in delayed days by responsible organisation: '13/14 – '16/17
Despite the NHS being attributable for the highest proportion of DTOCs (as seen in the previous graph), this shows the extent to which the problem in social care is growing. Over the past 3 year alone, DTOCs attributable to social care in an acute setting have almost tripled, rising by a staggering 188%. This compares with a 39% increase in DTOCs attributable to NHS in an acute setting. Albeit still a sizeable increase, this trend within social care highlights a marked, and clearly unsustainable, shift in social care’s capacity to deal with the current demands of the acute care industry.
Despite the NHS being attributable for the highest proportion of DTOCs (as seen in the previous graph), this shows the extent to which the problem in social care is growing. Over the past 3 years, DTOCs attributable to social care in an acute setting have almost tripled, rising by a staggering 188%. This compares with a 39% increase in DTOCs attributable to NHS in an acute setting. It's a sizeable increase, but this trend within social care highlights a marked, and clearly unsustainable, shift in social care’s capacity to deal with the current demands of the acute care industry.
To understand where the burden is being felt the most, it is worth breaking the statistics down by reason codes. Each DTOC, as recorded in the NHS England data set, has to be attributed to one of ten predetermined reason codes set out by NHS England. Below is a summary of all the attributed reasons for the 2013/14 and 2016/17 year.
Reasons for DTOC delayed days: '13/14 Vs. '16/17
Three years ago the two principle reasons that were given for recorded delayed transfers of care were a patient ‘awaiting further non-acute NHS care’ and ‘awaiting completion of assessment’. The third highest factor was ‘patient or family choice’. Today, in the 2016/17 year, there has been a massive shift towards patients ‘awaiting care package in own home’. Although this is potentially a reflection of the efforts to allow patients to retain their independence and therefore be discharged to their homes rather than other care facilities, it demonstrates the extent to which the current relationship between NHS and social care teams is not able to effectively facilitate this.
Breaking this one reason code down by attributable organisation, you can again see that from 2013/14 to 2016/17, the increase in DTOC delayed days was largely attributable to social care, and markedly worse in an acute setting in general.
DTOC delayed days – "Awaiting care package in own home": '13/14 Vs. '16/17
So what can be done to combat this?
There shouldn’t be anything in this blog that comes as a surprise to any reader familiar with the NHS. It is a well known and widely documented fact that DTOCs are a major challenge facing the NHS and one of the key reasons the NHS 5 year forward view is putting so much emphasis on developing truly integrated care systems for the future.
Therefore, from a strategic point of view, this information simply demonstrates how critical the success of STP’s will be in delivering a sustainable NHS in the future.
However, given the rate at which this situation seems to be deteriorating, there is another more tactical question to ask. Quite simply, can these acute providers afford to wait for the STP’s to take affect?
In a number of cases, the answer is probably not. It is clear that greater collaboration is required between acute and social care providers, which some Acute Trusts are already acting upon by housing social care teams on site and integrating them into the MDT. This is certainly an option that other Trusts may need to consider as a short term fix and is a concept I will explore in my next blog, which looks at the bigger picture of delayed discharges and patient flow in an acute setting.
Read the final blog in this 2 part series: DTOCs - A growing piece of a bigger problem >