Delayed transfers of care, or ‘DTOC’ as it is colloquially referred to in NHS circles, are an entrenched national problem. In simple terms, a delayed transfer occurs when a person in hospital, who is declared ‘medically fit’ to be ‘discharged’, is prevented from doing so. It is often claimed that a combination of cultural and structural factors are behind this. These range from an over-reliance on bed-based care to increasing numbers of people with complex conditions moving between providers and causing undue strain on the system. DTOC is one of the principal issues said to affect the performance of A&E units and hospital bed capacity up and down the country, year in, year out.
DTOC also has a big impact on the whole healthcare economy in terms of activity, costs and reputation. It is generally accepted that most of the cases centre on acute services for older people. But the question I pose is: by focusing on the hospital setting, are we concentrating efforts on the symptom or the cause? Every problem presents an opportunity. Every challenge requires a desire to improve by thinking and acting differently. DTOC is a symptom of a dysfunctional health care economy.
Activity Management: Playing Your Cards Right… or Wrong!
Concerted effort and numerous attempts have been made, over several years, to address DTOC. Yet, such schemes, fail to impact on DTOC as they compartmentalise the problem rather than understanding the root cause of the problems. Initiatives tend to adopt reactive and reductionist approaches. DTOC is a consequence of:
- Activity outsourcing of adult social care provision
- Multiple patient assessments
- Eligibility criteria in community and social care
- Different 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 focus on reducing length of stay
- A target mentality which limits attempts to understand to improve
- Understanding the problem from an organisational perspective
Older peoples pooled budgets offer hope to reduce DTOC rates. However, they are only effective if accompanied by a change in commissioning, operational thinking and ways of working that extends beyond joint ‘commissioning of care’.
Current DTOC performance is a snapshot of weekly data returns from local acute trusts. The process resembles the game-show ‘Play Your Cards Right’ as analysis shows that the weekly rates of DTOC can vary with some weeks being ‘higher’ and others ‘lower’. Monitoring the problem is not the same thing as understanding and getting to work removing the causes.
All of which leaves me with more questions than answers, and those questions are – what does this tell us? How does this information and monitoring help us to understand and 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 because 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.
Humanising Healthcare: A Different Perspective on the Problem
When problems are viewed from the right perspective, that of the patient, problems are soon seen in a very telling light. Starting with researching the problem, rather than establishing visions and project plans, provides a platform to overcome successive false starts. This enables identification of root causes and the design of a healthcare system that reduces DTOC levels, by better understanding of patient demand.
It begins with adopting a patient perspective and intelligent analysis of the problem. This work seeks to take a holistic approach and understand the key issues from the patient’s perspective. It asks what type, patterns, predictability and volume of activity are caused by certain numbers of patients, all of which relate to cost. This way of thinking and acting is the means to achieve intelligent change leading to sustainable performance improvement. I call it Humanising Healthcare.
When you compare A&E waiting time against DTOC rates it reveals different sets of challenges. You see external system problems where the hospital is trying to deal with the consequences of fragmented care. But the 4-hour A&E waiting time target paradoxically helps make the problem worse by driving admissions.
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, one large hospital case study showed that 1,700 patients were affected by a DTOC over a single 12-month period, this represented 0.65% of total number of patients that the hospital saw. The cumulative length of stay from their emergency admissions contributed to 33.3% of the overall bed capacity in one of the largest hospitals in the country.
While the example above shows the real costs of DTOC are much higher than a blinkered focus on ‘excess bed days’ would allow for (an abstract and unhelpful financial ‘tariff’ distinction). Every year in this same hospital more than £11million is spent on under 2,000 people without knowing if this money is well spent.
The small numbers show that the problem is predictable and therefore manageable. It also represents a big opportunity for healthcare leaders providing they have the courage to make profound changes in the way we commission and provide healthcare services. To reduce, and thereby improve, DTOC there is a need to gain a better understanding of patients and the services that they currently consume. This information is crucial to enable the design of more effective medical and non-medical services that are customised around patient care needs.
The issues affecting DTOC are complex. The mistake often made with improvement efforts is to try and cut through or standardise complexity. As W Ross Ashby’s Law of Requisite Variety teaches us, the most intelligent way to deal with variety is to design systems and services against that variety.
Regarding healthcare, this would imply that the best way is to understand and then design against patient-level demand. This means the issue should be understood and acted upon from a holistic point of view, and not simply seeing the problem as specific to one hospital. This means healthcare commissioners can no longer offer silo solutions such as financial incentives for hospitals to ‘do better’ by reducing their rates of DTOC.
A key alternative would be for commissioning to change; it needs to stop specifying outcomes and start collaborating with health and social care providers to help understand and to improve the nature of the problem. Once this is addressed, we can then begin to holistically redesign responsive services and systems against the type of patient variety we experience. Now that’s worthy of a ‘Brucie Bonus’!
Hamish Dibley is a Managing Consultant and Healthcare Lead with Capgemini Consulting. An experienced change management and service improvement professional, Hamish has delivered better service outcomes and cost reductions across NHS and adult social care. He has pioneered a new and digital-enabled way to better understand and improve services and systems, from the perspective of the patient. Humanising Healthcare fuses operational research and operational improvement expertise with astute strategic vision to achieve better service at less cost.