Dr Jo Andrews' piece on a whole system approach to reducing length of stay and occupied bed days, as featured in the Health Service Journal
Why ‘DToC’ needs to be removed from the NHS lexicon
In 2015, I went through something that completely changed my perspective on how we care for older people. I was moving from a career as an NHS consultant anaesthetist to join the consultancy firm Carnall Farrar, when my widowed mother had a minor fall at home and broke her ankle. She was an independent, highly articulate woman in reasonable health for her age. The break was bad, and needed surgery. The care my mother received was good, but she spent four days waiting for the operation, and a further week recuperating, before being discharged to a nursing home for 6 weeks because she could not weight bear. She returned to her own home some two months after she fell, unable to climb stairs, and needing daily support. Her confidence was diminished, and she was less able to cope with even minor crises. Finally, I understood what deconditioning was. The loss of physical capacity, confidence and independence is real, and the impact long lasting.
My mother’s case is trivial in comparison with the experiences of many older people who are admitted to hospital. The loss of physical function through loss of muscle mass, the risk of falls, pressure damage, acquired infection and particularly for those with dementia or cognitive impairment, confusion and delirium all have a significant impact on peoples’ ability to live independently. The longer people spend in hospital, the greater the impact. It’s bad for them, and ultimately means more people needing more care sooner than they would otherwise do. Getting people out of hospital as soon as they no longer need to be there should be a clinical, financial and humanitarian imperative.
The headlines would have you believe that at any one time about 6,000 people are affected by a delay in transferring from hospital. We don’t know how many people a year spend time classified as a Delayed Transfer of Care (DToC), or for how long, because we count days not people. DToC was designed to create a financial incentive for local authorities to provide the services they were obliged to, by requiring them to pay a fine to the health sector when they didn’t. The process requires a detailed set of criteria to be met to determine whether someone is a DToC, and then assigns responsibility for the delay to health or social care. This is time consuming, bureaucratic, adds no value to the patient’s care, and is also damaging to partnership working. Just as our rhetoric of integration gathers weight and commitment we continually measure something that implies ‘my poor performance is your fault’, creating antagonism between health and social care with the patient in the middle. More importantly though, it ignores a much larger group of patients who are medically fit to leave hospital, and yet remain in a hospital bed.
'We have found 30% of acute beds and 38% of community beds are occupied by patients who are medically fit to leave.'
Over the last two years, Carnall Farrar has conducted bed audits across several STPs, building on the excellent work undertaken by Public Health in Devon. In total, these audits cover 8% of the acute bed stock, and 9% of the community bed stock in England; we have also audited mental health beds in three areas. We have found 30% of acute beds and 38% of community beds are occupied by patients who are medically fit to leave. Extrapolating this to the national bed base, we estimate 28,000 beds could be freed if patients moved to a more appropriate setting of care no more than one day after becoming medically fit. Fewer than one in four of the patients identified as medically fit to leave in our bed audits were classified as a DToC. We are massively underestimating the scale of the issue.
It would be tempting to dismiss the difference in the two figures as patients who are due to be discharged very soon, and for whom therefore the clinical impact of this delay is not so great. Unfortunately, this isn’t the case. 46% of patients audited had been medically ready to leave their current setting of care for four days or more.
So what are the barriers to patients leaving? Clearly an overstretched social care system is one component, and delays due to social care have increased significantly in the last five years. Addressing the needs of an increasingly complex group of patients requires a different range of services to those currently available, and simply increasing social care capacity won’t be sufficient. But delaying discharge doesn’t decrease the amount of care patients ultimately need. In fact, the evidence all points in the opposite direction: delaying discharge increases long term physical and psychological dependence. Our current approach to managing scarce resources is making the problem worse.
Addressing this requires changes within the hospitals themselves, at the interface with out of hospital services and in the community. For hospitals, many of the changes are well understood, focussing on early mobilisation, and discharge planning. Interfaces need to be seamless, with decisions made rapidly and supported by shared data. The greatest transformation though has to be in community service offerings which need to support safe, prompt discharge. This cannot and must not be about providing the same care somewhere else; health and care systems have to work together to identify and put in place the services needed by this group of patients, at a scale that ensures they are sustainable.
Delivering these services requires moving the resource, which is currently locked into providing care in hospital for patients who don’t need to be there, out of hospital. We estimate the current cost of delivering care in hospital to patients who are medically fit to be over £3bn, and the reinvestment required in new services to be between £600m and £1bn. There is scope both to move resource and address over-occupancy in hospital.
'We estimate the current cost of delivering care in hospital to patients who are medically fit to be over £3bn.'
We seem to be trapped in a pattern of care that keeps people in hospital beds because we haven’t fully understood the harm this can do them, and haven’t prioritised putting in place the services they need if they are to be cared for elsewhere. The beds they are occupying are needed for other emergency patients, who at the moment can’t get out of Emergency Departments, and for elective patients whose surgery is cancelled for the lack of a bed. All of this creates a cycle of waste, with clinical teams unable to deliver the care they want to, and that their patients need.
We need to stop talking about DToC, and focus instead on how we help every patient get to the right setting of care for their needs. It’s the right thing for patients, for staff and for systems.Read the full publication here