Analysed: Delayed transfers of care in Oxfordshire
This HSJ Local Briefing looks at how the health and social care economy in Oxfordshire can control its rate of delayed transfers of care.
ISSUE: Oxfordshire has the highest rate of delayed transfers of care in England, reporting 66,000 delayed days in the year to June 2012 - a rate of 129.5 per thousand adult population.
CONTEXT: The health economy has had a long-standing delayed discharges problem, which became the highest in the country during 2011. The rate has declined since March 2012, but remains well ahead of the next worst area. Local leaders blame a complex mix of local cultural factors and an over-reliance on bed-based care but, encouragingly, not each other.
OUTCOME: Leaders at all the Oxfordshire commissioner, provider and social care bodies have agreed a programme of work to restructure local services and increase understanding between clinicians in different parts of the system. A pooled budget for health and social care services has also been agreed, but only in principle so far.
The national picture
Delayed transfers of care is an entrenched national problem that local and national level efficiency programmes have struggled to control over the past two years.
HSJ analysis of Department of Health data shows that the rolling 12 month total remained between 1.37 million and 1.39 million from July 2011 – the earliest point for which a full year of data is available – to June this year. As each delayed day costs an estimated £240 to £300, this amounts to a total annual cost of as much as £417m.
Within the overall figures, there has been a 9 per cent rise in the number of cases where a patient has been awaiting non-acute NHS care – from 246,032 to 267,954. The category includes community hospital services, mental health services, and NHS-funded continuing healthcare in the private sector. However, it does not include community services provided in a patient’s own home.
This suggests that, although the NHS is getting better at smoothing some transition between care settings, the parts of the system where people with complex conditions are moving between providers are under increasing strain.
Delayed transfers between NHS organisations are on the rise, accounting for 71 per cent of the total in June 2012, compared with 65 per cent in August 2010.
Sir John Oldham, national quality, innovation, productivity and prevention lead for long-term conditions and urgent care, predicts that delayed transfers are likely to remain at their current level until 2013-14 or 2015. Real transformation, he argues, will require profound changes to the way health and social care are delivered locally and supporting people to manage their own care.
Performance in Oxfordshire
Oxfordshire has by far the worst rate of delayed transfers of care in the country, with 129.5 per thousand adult population over the year to June 2012. The next worst local authority area is Sandwell with 77.8, while the national median figure stood at 26.6.
That means that in the 12 months to June 2012, there were more than 66,000 delayed days across the county. The situation has been described by Oxfordshire Clinical Commissioning Group accountable officer Stephen Richards as a “debacle”.
The county’s 2012 peak came in March, when there were 6,332 delayed days in the month. Steady declines since then have brought the level down to just under 5,000.
Overall the social care sector is responsible of a bigger proportion of delayed transfers of care in Oxfordshire than it is in England as a whole. In Oxfordshire it made up 32 per cent of delayed transfers from April 2011 to June 2012 - two to three percentage points more than was the case nationally. However, social care has made a higher proportion recently in Oxfordshire - over 37 per cent every month since March.
However, other datasets tell a slightly different story. The health economy monitors performance via a snapshot taken on one day each week, and local analysis has not found any proportional change in delays attributable to social care. Sources say the most stubborn delays are between NHS providers.
These snapshot figures show a similar March peak, with 201 delays in a single day, falling to 130 by early August - although local managers cautiously attribute half of that improvement to seasonal factors.
The major players
The Oxfordshire health and social care economy is relatively neatly structured, which is encouraging as it ought to make integration and joint working simpler. There is a single CCG for the county, which took ownership of the delayed transfers issue in early 2012. This shares boundaries with Oxfordshire County Council, the provider of social care services and intermediate care.
There is one acute trust: Oxford University Hospitals Trust. It operates the enormous John Radcliffe Hospital, the smaller Horton General Hospital and the Nuffield Orthopaedic Centre. Although it is a major tertiary provider, the delayed transfers problem is generally accepted to centre on general acute services for older people. Finally, there is a single provider of mental health and community services for the county: Oxford Health Foundation Trust.
Leaders from all these organisations have been working together on the issue for some months. They broadly agree the delayed transfers problem has two major drivers: how services are structured locally and local cultural factors.
The average person in residential care lives in a nursing home for three years in Oxfordshire - twice the national average. One local figure said this was symptomatic of an over-reliance on bed based care, and pointed to an under-provision locally of services supporting people to live in their own homes. Instead, Oxfordshire patients are more likely to be institutionalised and when they are, they are kept in for longer.
About half of all local delays are between acute care and community hospitals. Oxfordshire is unusual in that it has a large number of non-acute beds - around 200 spread among nine community hospitals, for a population of around 650,000. Local sources say this is because the county never kept pace with other parts of the country, which have worked to replace non-acute beds with home-based care over the past decade. There are more community beds in the south of the county than the north, and the facilities are well loved by the communities they serve.
But they complicate local care pathways. Patients who in other parts of the country would be able to go straight home from an acute bed and receive treatment from community nursing teams, instead go through a two-stage process, from acute to community bed and then home from there.
However local leaders do not plan to simply close local community hospitals and spend the money on home care. Instead, it is hoped that those facilities can be used to provide outpatient services, and “step up” beds for patients usually receiving primary care whose conditions have worsened but do not necessarily require a full-blown acute admission. This in turn could cut acute admission rates - Oxford University Hospitals hopes to be able to break the vicious circle in which delayed transfers place extra demand on their services, preventing commissioners from reinvesting in home care services, which reinforces the delayed transfers issue. They hope to be able to reduce their total bed count by as much as 150 as, at any one time, about 18 per cent of their inpatients do not need to be in hospital.
Happily, a solution based around reinventing existing community facilities would save commissioners from trying to persuade vociferous local communities that they’re better off without bricks and mortar services on their doorstep. It would also avoid a politically intriguing scenario emerging, in which one of the first locally visible acts of the reformed NHS was an attempt to close a 60 bed community hospital in prime minister David Cameron’s Witney constituency.
There is a smaller, but interesting, problem brought about by the transition to the new NHS structure. The community hospitals are still owned by Oxfordshire Primary Care Trust, which provided community services until April 2011, when they transferred to Oxford Health under the transforming community services programme. It has not yet been decided whether, after the abolition of PCTs next year, the buildings will be owned by Oxford Health or NHS Property Services Limited – and a decision might not come until the end of 2012. At the moment no one is talking about Oxford Health selling off community hospitals to generate capital to invest in other services. But if it did acquire them, Oxford Health would be able to use those properties as collateral to borrow against, for instance to invest in home care technologies. A decision on property would enable Oxford Health to plan capital investment over the long term. “Some clarity would be appreciated”, one local figure told HSJ.
Although delayed transfers are a symptom of a dysfunctional health economy in which the various partners are failing to cooperate, it is striking that on this issue all the leaders in Oxfordshire agree on the causes and do not simply blame the problem on each other. If there are disconnects, they appear to be at a clinical rather than a managerial level. To tackle this, local health leaders have begun a project involving around 140 frontline staff from social services, GPs, and both local provider trusts to increase trust and cooperation at all levels of the local health economy.
One local source said the unnamed scheme, which is running through August and September, “acknowledges there’s a level of conservatism” among clinicians in Oxfordshire. Ironically, that risk-aversion is contributing to the area’s poor performance on delayed transfers, which is putting improved care and efficiency savings at risk. “We’re trying to get everyone together so colleagues in the acute hospital know and realise the skill and expertise of social care, primary care and community care colleagues,” HSJ was told. It is vital that doctors understand that they do not have to hold on to patients “until they’re perfect”, and that they can pass them on to other parts of the system confident that they will receive the treatment they need.
There is also a widespread agreement that, in place of trust and cooperation, the Oxfordshire system has become too reliant on “endless” patient assessments before transfers can take place. Senior figures hope that building trust and understanding between clinicians in various organisations will help foster a less bureaucratic culture around transfers.
The choice question
A second cultural problem exists among patients, HSJ understands. A side-effect of having lots of community hospitals so cherished by local people is that it can be hard to transfer patients to a site other than the one in their own town. Around 10 per cent of delayed transfers occur when a patient is offered a place in a community hospital which they do not want to go into. Some patients would rather sit in the John Radcliffe Hospital and wait for days for a bed to become available in their local community hospital – and in some cases they are being allowed to do so.
“This is an area we have to address”, one senior local source told HSJ. “If we don’t look at choice we won’t be doing the job properly.” The system plans to launch a “major public education and explanation programme” to make it clear to patients “if you need to go to a community hospital bed, or a nursing home bed, and you’re in an acute bed, your right of choice is not in that acute bed.”
No new policy on choice is needed – the existing one just needs to be implemented properly. Again, this will involve local health leaders working closely with clinical staff to change attitudes and behaviours on the front line.
One final factor that is making it more difficult to restructure local services is recruitment – a system with fewer delayed transfers of care would have greater capacity to treat people in their own homes. This is not possible without larger teams of social care and district nurses, but local providers struggle to fill these posts. It is believed that part of the reason for this is that Oxfordshire is a relatively affluent part of England, and it is difficult to attract local people into low-paid, under-valued jobs.
The council has outsourced all its social care provision, so cannot control the issue directly. HSJ understands officials are working with providers on workforce strategies. Meanwhile Oxford Health is reviewing its recruitment processes – simply placing an advert on NHS Jobs has not been enough to attract a sufficient volume of suitable candidates – and bringing in new, more flexible contracts to enable them to bring in more staff when they need to. Both bodies are working to find ways of making those traditionally low-status jobs more valued – but without paying them more.
The best hope in the Oxfordshire health economy rests on plans to pool health and social care spending. The move has been agreed in principle by the CCG and the council and if all goes well could be implemented in some form by the beginning of 2013-14.
Even the best case scenario – that a pooled budget is created to be spent on home care services that enable older patients to be transferred quickly out of the acute sector, could prove controversial. It is widely expected that social care budgets will be squeezed harder over the coming years than NHS funding. That means that each year the NHS contribution to the pooled budget will get proportionally bigger - local acute clinicians might justifiably feel that their services are being shrunk to bail out social care and community services. Managers sensibly argue that acute doctors do not want to be caring for people who do not medically need to be there, let alone working in a system that does not act in patients’ best interests. When hospital wards begin to shut, it will be possible to see how well local leaders have been able to influence the local culture among clinicians.
Health and social care budgets were “aligned” throughout the last couple of years as delayed transfers problem worsened. Alignment failed because ultimately the council and the NHS retained accountability for their separate revenue streams and services.
It is believed that a pooled budget would enable greater integration of health and social care services by making joint commissioning much easier. It should also remove any residual perverse financial incentives which in theory pull against the stated intention to use all local services to the benefit of patients. Under a pooled financial arrangement, for example, there would be no disincentive for social care to take a patient as early as possible, unlike currently where each day’s delay saves those services money.
However necessary budget-pooling seems, it is not yet a certainty. All the important details, such as who would hold the budget and who would be accountable for it still have to be worked out. It is also yet to be decided exactly which funds would be involved, although it has been agreed to pool cash for older people but not funding for services for physical disability.
Currently £130m sits in the aligned budgets, around £40m of which is from the NHS. However commissioners will not agree to pooling unless they are convinced that the budgets relate to the populations who are most at risk of delayed transfers. At the moment, they are not sure.
One well-placed figure said: “We have to look at proportionality and ask is it right – is social care putting in too much, and is health putting in enough?” Then the funding has to be reallocated to schemes that will keep patients out of hospital. Over the coming months the CCG and local authority will have to have some incredibly detailed discussions to agree how to spend the pooled money.
The success or otherwise of those discussions, and the wider joint working on this issue should be visible within the next six months in the form of pooled budgets, service redesign plans and, hopefully, a substantial fall in the local rate of delayed transfers.