‘Come together, right now, over me’? Delayed Transfers of Care affect partners and patients across the system – but how can organisations work effectively together to tackle the issue?’

27 November 2017

David Segal, Principal Consultant

Fixing delayed transfers of care – more to it than just topping the table

The issue

Throughout 2017, tacking Delayed Transfers of Care (DTOC) has been a strong focus of the health and social care improvement agenda. Earlier in the year, HSJ provided a run-down of the best and worst performing Trusts and an ominous look at NHS England’s target of 3.5% - a target that is already being missed in many areas, and if trends continue will get worse and not better.

Top 3 - based on average DTOC Rate

DTOC   tOP 3

Bottom 3 - based on average DTOC Rate


The good, the bad, and the ugly? So is it as simple as looking at the league tables to identify the local systems that have got it right and those have got it wrong? Does DToC data have all the answers, detecting the exact problem in the system and allowing us to tailor exact solutions? The answer of course is no, and looking at the league table for January to March brings up different players in both the best and worst spots. The answer however isn’t to ignore these league tables completely. High levels of DToC might not explain the cause of a problem or the true severity, but it does have a real impact and is a symptom of something that has gone wrong. To use a crude analogy, DToC is like the bad headache of the health and care system. Even the worst headache may have a relatively harmless route cause, but if left untreated and without investigation, severe consequences could emerge.

Key Takeaways The more detailed DTOC information can guide our focus when looking for solution, however our experience has shown that building in some key lessons learnt from our ‘top performers’ will have the biggest impact on longer term reduction to delays. Here are just three lessons that should feature in the thinking for any challenge and potential solution:

  1. Change anywhere in the system can reduce DToC. High DToC in a local economy puts a magnify glass inside the hospital walls, but solving issues in the hospital often moves DTOC to the next place. Providing a comprehensive safety net in the community creates a powerful pull effect for patients ready to go home.
  2. Capitalise on talent but don’t rely on individual personalities. Success will always require the incredible efforts seen from staff across the system, but a slip down the league tables can be caused by the simple departure of a key individual. Systems must embed and systemise good practice to ensure long term success whatever the change in personnel.
  3. Make the patient the centre of everything. Of course systems will consider patient outcomes when making a change, but making the patient the centre of all considerations throughout the process will lead to much greater success than detailed analysis of DToC categories. Asking how a change will improve a patient outcome is more likely to achieve a reduction in DToC in the long run.

Eilidh Cunningham, Analyst

‘There’s no place like home’ - Mental Health Delayed Transfers of Care are on the rise, so how can partners work effectively together to support patients to return home?

The buzzword this year is DToC - Delayed transfers of care. These delays cause problems for both patients, as they lead to unnecessarily extended stays, and NHS services, as they reduce capacity to admit, move or discharge patients.

What is the current situation?

The NHS requested an immediate emergency cash injection to enable it to manage patient safety risk this winter but in Philip Hammond’s Autumn budget less than half of the £4bn requested was allocated. Alongside this, the budget failed to draw attention to mental health (MH) services for children and young people, which from recent findings have DToC figures that are increasingly becoming more concerning as winter proceeds. With 1 in 4 adults and 1 in 10 children experiencing mental illness per year it is unsurprising that this is the case.

We neglect the impact that MH DToC can have on the system because there are fewer MH beds. However, most MH patients stay in hospital longer than is needed, causing system DToC figures to rise, alongside leading to patients suffering unnecessarily if the best place for them to be is in alternate housing provision or at home.

Why are MH DToC worse in winter?

Although MH issues are a year-round problem, winter weather and potential loneliness over the holidays can make coping more challenging. Alongside this, the Mental Health Foundation reports that 1 in 15 people in the UK are affected by Seasonal Affective Disorder (SAD) . For some sufferers, SAD can be so crippling that it leads to continuous treatment, adding further pressures to the MH trusts.

Three top tips for improving mental health DToC

At a recent Pan London Reducing delays in Mental Health Trust discharges workshop, attended by colleagues from across health, social care and the voluntary sector, a series of top tips were developed based on experience and best practice. Key takeaways:

• Involve Housing at all stages: 60% of people with poor housing conditions report MH problems. Recognising the importance of safe and stable housing for individuals is not only an essential part of recovery, but it also enables people who are homeless or require housing to have a clear route home from hospital. Joint-working arrangements include basing housing officers at the hospital who are proactive on wards and involved in weekly bed management meetings.

• Real multi agency working: Ensuring a real commitment from agencies to prioritise a weekly meeting to discuss the reasons for delays in transfers of care. These meetings can be used to identify actions with a clear owner to ensure things move forward.

• Commitment at a leadership level to commission and work together: To achieve real multi-disciplinary working, there needs to be a joint statement and service level agreement for key stakeholders to work together. This should go beyond the creation of a joint vision and a weekly phone call. It needs to be a real commitment to culture change and collaborative working within their relevant organisations to ensure no one is in a mental health bed unless it is the best place for them to be.