Analysed: The best and worst regions for delayed transfers of care

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Map: how has your region performed on transfers of care?

Delayed transfers of care have risen steadily for the past two years and are becoming a major area of policy focus during 2016. HSJ’s detailed analysis of local delayed transfers figures reveals:

the areas in England with highest rate of delayed transfers per head of population;
the areas experiencing the sharpest rises in delayed transfers;
the most improved – areas which are succeeding in bending the curve of rising delays; and
the strongest performers on delayed transfers.

In a sign of the rising level of concern in Whitehall, better care fund guidance for 2016-17 instructs health and social care leaders to develop action plans for managing DTOCs, and come up with a “stretching” plan for cutting the rate of delays. This target will be reflected in clinical commissioning groups’ operational plans next year. Local systems will now be in the process of defining the target and agreeing their plan to cut the rate of delays.

There has been a rise nationally in delayed days of 20 per cent over the past year, despite the introduction of the better care fund. In October 2014, health secretary Jeremy Hunt said the policy would cut delayed days by more than 100,000 a year across the country – at the time meaning a cut of 7.5 per cent.

HSJ’s analysis of delayed transfers has found that some areas have experienced much more extreme increases than seen for the country as a whole.

We have also identified the areas where the DTOC rate per head of population far exceeds the national average. The rate in Oxfordshire, for instance, is almost three times the national figure, while Northamptonshire and Cornwall both have rates more than double that of the England average, with Coventry not far behind.

Our analysis has also highlighted the best performers on delayed transfers – those who, despite the national trends of rising delays, rising hospital admissions and an ageing population, have still managed to cut their rates (see box, below).

Although the City of London’s strong performance can probably be discounted because of its small population, many predominantly urban areas in the Midlands and the North cut their DTOC rates over the year to December 2015.

The achievements of the integrated care exemplar Torbay is underlined by our interactive map. Torbay is visible on the South West coast as a sliver of green on the edge of an expanse of red – meaning it is unique among its neighbours in outperforming the national average.

We have also identified the places with the lowest DTOC rates. London makes a strong showing, with five boroughs in the top 15 performers. No London boroughs have a rate of DTOC per head of population above the national average.

‘Relentless focus’: How to keep delayed transfers down

Areas that have kept delayed transfers of care low have told HSJ that improving flow from the wards into other parts of the health and care system is quite simple, but requires joint ownership of the problem by all parts of the system.

There also has to be a consistent focus from all parts of the system on assessing and discharging patients from the moment they are admitted. Nancy O’Neill, director of collaboration across the clinical commissioning groups and local authority in Bradford, described a “relentless” focus on “pulling” patients through the acute sector, rather than trying to “push” them out of the hospital’s back door once they are ready to leave.

Leaders in Oldham, which has the third lowest DTOC rate in the country, have set up a team to quickly develop a discharge plan for elderly patients as soon as possible after they have been admitted. The team covers the health and care sectors and is clinically led.

Sandwell, which achieved one of the most significant drops in DTOCs over the year to November 2015, introduced similar discharge support teams which assess patients’ needs and match them to the packages of home care or residential care they will need when they leave.

Sandwell and West Birmingham CCG chair Nick Harding said: “I don’t think this is a magic bullet, it’s nothing clever, it’s just everyone saying we can all own the problem together.”

Sandwell and West Birmingham Hospitals Trust trust sits across the border of Birmingham and Sandwell councils. In contrast to the strong performance in Sandwell, Birmingham’s DTOC performance is significantly above the England average and is rising. Trust chief executive Toby Lewis said Birmingham is beginning to adopt the practices already well established in Sandwell, and he expected delays for Birmingham patients to reduce as these are embedded.

Mr Lewis added that it was “not obvious that the [better care fund] has contributed to those improvements” in DTOCs seen in Sandwell over the past year. However, other NHS leaders told HSJ that while the policy has not provided a solution to the DTOC problem, it has carved out money to enable new ways of working to be established where the will exists among NHS and council partners.

DTOC and accident and emergency performance are both closely associated with patient flow through the acute sector, and DTOCs are commonly cited as a reason for delays in A&E admissions. However, it is far from clear that strong results on DTOCs will lead to better A&E performance. Portsmouth, for instance, has done well on delayed transfers but has persistently struggled on A&E. There are many similar examples where performance on the two indicators does not match up.

A new front in the war on DTOCs is patient choice. HSJ has been told anecdotally that some delays are due to patients preferring to wait for a place at a particular care home, rather than take the first that is offered. Mr Lewis said the Sandwell system was becoming more “disciplined” in setting out timescales for families to make their choices, and beginning this process early in their hospital stay rather than at the point they are fit to leave.

Ms O’Neill said some of the remaining DTOCs in the Bradford system were also down to patient choice holding up discharge.

The council in Northamptonshire, which has the second highest DTOC rate in England, also highlighted patient choice. A spokesman said: “Hospitals have also introduced a choice policy for patients and their families which will establish the amount of time that a family can spend looking for residential care or home care if they self-fund.”