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Delaying the inevitable: a better way to think about delayed transfers of care

DTOCDelayed 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.

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