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Delayed transfers of care, or ‘DTOC’ as it is colloquially referred to in NHS circles, is an entrenched national problem. It is often claimed that a combination of ‘cultural and structural factors’, an over-reliance in bed-based care and increasing numbers of people with complex conditions moving between providers is causing undue strain on the system. It is one of the principal issues said to affect the performance of A&E units up and down the country.
DTOC has a big impact across the whole healthcare economy in terms of activity, costs and reputation. It is generally accepted to centre on acute services for older people. But the question I pose is: by focusing on the acute are we concentrating efforts on the symptom or the cause? Every problem presents an opportunity. Every challenge requires an intention to signal a desire to improve through thinking and acting differently. DTOC is a symptom of a dysfunctional health care economy.
Concerted effort and numerous attempts have been made, over several years, to successfully address DTOC. These initiatives include the usual list of initiatives including ‘Appropriate Care for Everyone Programmes’ (without ever defining what appropriate in this context means), QIPP projects, engagement and public education packages and Older People’s Joint Commissioning Strategies.
Yet, successive schemes fail to impact on DTOC as they compartmentalise the problem through focusing on urgent care or complex care rather than understanding the root cause of the problems. The impact of these actions on improving DTOC performance remains stubbornly low. Initiatives tend to adopt a reactive and reductionist approach to resolving the problem.
The principal reasons for failure requires detailed study but can be summarised by adopting a (silo) service-first not patient-perspective and focusing on activity reduction and discharge pathways. The causes of waste or ‘system limitations’ affecting DTOC include:
- Outsourcing of adult social care provision
- Multiple patient assessments
- Eligibility criteria in community and social care
- Different organisational budgets, performance metrics and ways of working
- Counter-productive financial incentives across the system
- Service fragmentation such as a ‘medically fit’ focus
- Alleged risk-averse attitudes amongst some clinical staff
- An efficiency rather than effectiveness focus on reducing length of stay
- A target mentality which limits attempts to understand in order to improve
- Understanding the problem from the organisational perspective
‘Pooled budgets’ for services used by older people offers hope to reduce rates but only if it is accompanied by a change in commissioning and operational thinking and ways of working that extends beyond joint ‘commissioning of care’.
‘Current DTOC performance’ is monitored on a regular basis through weekly returns taken on one day each week from local acute trusts. The whole thing resembles the game-show Play Your Cards Right. Snapshot analysis shows the weekly rates of DTOC can vary with some weeks being ‘higher’ and others ‘lower’.
All of which leaves me with more questions than answers, and those questions are – what does this tell us? How does this information help us understand to improve? Does this ‘activity counting’ help develop knowledge and understanding around the patients who experience delays and the type and nature of activity this creates which leads to costs? What has operationally changed as a result of monitoring? How do we know if this has been effective? Or like the game show – is it simply a game of chance? Such ‘activity monitoring’ is as counter-productive as it is distorting. Improvement work must take place in the work not in meeting rooms.
I have recently completed a piece of work looking at the problem. I hope the study will provide the platform to overcome successive false starts, identify root causes and design a healthcare system to reduce DTOC levels through better understanding patient demand. But that, of course, is dependent on the willingness of local NHS leaders to adopt a different mindset.
It begins with adopting a different patient-centred perspective and intelligently analysing the problem. This work seeks to take a holistic approach and understand it from the patient perspective. It asks how many patients cause what type, patterns, predictability and volume of activity which results in costs. This way of thinking and acting is the means to achieve intelligent change leading to sustainable performance improvement.
What you discover is that the DTOC problem is NOT a general acute service for older people problem; hospitals deal with the consequences of the issue. When you compare A&E waiting time against DTOC rates it reveals different sets of challenges. One lot are external system problems where the acute provider is trying to deal with the consequences of fragmented care. But there are also internal system issues such as the impact of the 4-hour waiting time target which distorts performance and paradoxically helps make the problem worse (see my previous blog on the deficiencies with the A&E waiting time target).
As ever with healthcare, DTOC is a ‘vital few’ challenge – small numbers of patients consuming disproportionately high levels of activity, capacity and resources. For example, 1,700 patients admitted suffered with a DTOC over a 12 month period. The length of stay from their emergency admissions contributed to a third of the overall bed capacity of the hospital. Moreover, the real costs of DTOC are much higher than simply a blinkered focus on ‘excess bed days’ would allow for (an abstract and unhelpful financial ‘tariff’ distinction). Less than 2,000 people cost this particular secondary care system over £11 million every year. How much of this money is well spent? We simply don’t know.
But the small numbers show that the problem is predictable and therefore manageable. It also represents a big opportunity providing healthcare leaders have the courage to make profound changes in the way we commission and provide healthcare services. To improve (and thereby reduce) DTOC there is a need to better understand patients and what services they already consume to design more effective medical and non-medical services around their care needs.
The issues affecting DTOC are complex. The mistake often made with improvement efforts is to try and cut through or standardise complexity. Wrong. As W Ross Ashby’s Law of Requisite Variety teaches us the most intelligent way to deal with variety is design systems and services against that variety. In healthcare the way to undertake this is to understand and then design against patient-level demand. This will be effective and if you think about it, if you are effective at something; by definition you will be efficient.
Rather predictably, the political debate over the latest crisis afflicting the NHS is generating more heat than light. Superficially rules. Discourse reduces itself to a reverse Dutch auction over who can promise more cash whilst at the same time compete to declare unconditional support for the NHS. Stephen Dorrell, former Health Secretary and Chair of the Health Select Committee is on to something when he was quoted in The Economist magazine last year saying that anyone who tries to introduce knowledge and understanding to the issues ‘quickly finds out what it must have felt like to be regarded as a heretic in a more religious age’.
Fast forward to the begininng of a new year and we see numerous acute hospitals triggering ‘major incidents’ in response to ‘unprecedented levels of demand’. Their response is often to hold ‘extraordinary meetings’ that occur with such regularly they lose their original connotation. Hopes that periodic cash injections like the multi-million ‘winter bed pressure’ funding or ad-hoc ‘urgent summits’ will resolve the current predictable morass facing acute NHS hospitals is a fool’s paradise.
In fact, we have worn out all the possible tinkering approaches: from restructuring and merging hospitals to only achieve bigger problems; deliberately fragmenting the healthcare system so that no one reliably knows who is doing what, why, when and where; successive bouts of IT-led change that cost more than the benefits derived by both patients or professionals; imposing arbitrary targets that distort behaviour (such as the ubiquitous 4-hour waiting time indicator or referral to treatment times) and lead to ‘gaming’; increasing capacity which makes performance worse to rationing care (particularly in community and social care settings) that results in a false economy.
Indeed, the belief that we can simply talk or spend our way of trouble is indicative of a paucity of understanding. It is worth remembering that since 2000 we have tripled public expenditure on the NHS but not experienced service improvements consummate with such investment. Years later we still feel the need for calamity talks and emergency bailouts.
Such inertia and belief in extra expenditure is a costly distraction from consideration of the real problem facing the NHS; namely that we have an outdated model of healthcare that is capacity-constrained not demand-led. The current crisis of increasing attendance and admission rates (not the same thing as increasing numbers of people) to A&E is one consequence but not the primary cause of the turmoil.
It is possible to achieve the holy grail of healthcare: better care at less cost but this will require a complete resetting of how we intelligently manage, lead and apportion expenditure across the whole system. The only way that will work is to understand the nature of patient demand that appears and then develop a coordinated healthcare response (through redesigning broken systems, processes and payment mechanisms) that meets local needs – no more, no less.
Today’s King’s Fund inspired Barker Commission on the future health and social care in England calls for a new health and social care settlement, proposing the merger of NHS and social care systems. It calls for a new approach that redesigns care around individual needs regardless of diagnosis based upon a single ring-fenced budget with one commissioner per local area. Obviously, this has fundamental structural implications for the NHS as well as central and local government.
Alas Barker makes the same ‘back-to-front’ thinking mistake as the Dilnot review (and the government’s response last year) into funding social care. Both publications start from the wrong perspective: that to achieve genuine health and social care integration and serve peoples’ needs requires more not less resource.
The argument contained in the Barker report boils down to an out-dated and fragmented system being unable to meet the expenditure pressures of an ageing population with rising number of people who have long-term conditions. Merging NHS and social care systems therefore can create a fairer, free at the point of use system or ‘equal support for equal need’. Well up to a point.
Barker’s proposals advocate for a phased approach over time to ensure financial affordability. What this means is that it is proposed that social care eligibility criteria remains in place with only the fewest people with the highest ‘critical’ needs receiving free care.
Subject to economic improvement, coverage could be extended to those with ‘substantial’ needs. A new ‘Care and Support Allowance’ would offer ‘choice and control’ to people with ‘low’ and ‘moderate’ needs but would not remove the principal of means-testing.
Yet, the existence of eligibility criteria does not save money. The longer a person waits for care, the more likely it is that their condition(s) will worsen. It simply stores-up greater problems, resulting in no support for large numbers of people that only creates larger costs over time.
Dilnot meanwhile represents the worse kind of sticky-plaster solution, based on dodgy data of projected demand for services, out-of-date unit costs for domiciliary and residential care and misguided behavioural assumptions over people’s willingness to take out care insurance.
Its accepted proposal, the cap-cost model for social care, to be introduced in 2016, is unlikely to lead to a market for pre-funded care insurance. Economic modelling undertaken did not take into account variation but instead utilises the ‘average of averages’ for both residential care stay and care costs. Moreover, the care cap and means-tested threshold simply entrench fragmentation and disconnect between health and social care services.
Taken together these two reviews seemingly have a blinkered focus on funding allocation that assumes more care demands equal more resources and that there is no bad money or waste in health and social care activities, processes and systems. This is an entirely false assumption to make. Given the publication of the Barker Commission and resulting obsession with bandying around funding cap and eligibility threshold figures perhaps we could focus on a few telling ones?
During the lifetime of the current government spending review the NHS will provide £7.2 billion of support to local authorities for ‘health-related needs’ in the provision of social care. We presently spend £111 billion on the NHS and £17 billion on social care. We know that typically 70 percent of patients in NHS hospitals have social care, not acute medical, needs. We should be asking ourselves if we actually have a funding crisis or whether we have a failure to intelligently lead, manage and spend crisis.