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Declarations of victory on delayed transfers of care are potentially premature

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A guest briefing from Health Service Journal.

NHS England and the Local Government Association both declared qualified victories on delayed discharges last week. But have they both called it a little too soon?

Improving patient flow throughout the health and social care system remains a key issue vexing system leaders as an endless winter drags on. 

Emergency performance may have slumped to a new worst ever last month, and elective cancellations also hit a record low. But NHS and council chiefs have both cited efforts on a key flow measure, delayed transfers of care, as a Good News Story.

NHS England boss Simon Stevens told the public accounts committee last Monday that the health service had “genuinely turned the corner” on delayed discharges and praised “great progress on whole-system working”.

Mr Stevens told MPs: “We were able to free up nearly 2,000 DTOC beds come this January… the best DTOC position… in two and a half years.”

LGA chair Lord Porter was, meanwhile, in full rallying cry, declaring that local government improvements had far outstripped those of the NHS and Mr Stevens was being “parochial”.

The Conservative peer pointed to analysis by Impower and Local Government Chronicle, which said NHS attributed delays had increased by 4.7 per cent over between December and January, while delays due to social care had fallen by 2.7 per cent.

He said the LGA would now be able to “start standing up” to Mr Stevens.

The two sides’ bitter row began last summer following ministers threatening funding cuts for councils, if they failed to deliver DTOC targets. Depressingly, it rumbles on.

So much for “whole system working”.

But credit where credit’s due to both councils and the NHS. DTOCs appear to have significantly reduced from a high water mark in February 2017, of a reported 6,660 DTOC beds across both NHS and social care attributed delays. And the overall trend has since then been going broadly in the right direction.

A quick health warning on the DTOC data: it’s infamously unreliable. So, it’s more a means of determining direction of travel, rather than a statistically rigorous conclusion.

Total hospital bed days taken up by delayed transfers reduced from 5.6 per cent in the third quarter of 2016-17 to 4.5 per cent in the same period this year, notes Health Foundation senior policy fellow Tim Gardner.

This is “welcome progress”, he says, but must come with the caveat that there is still clearly further to go. The system missed NHS England’s 2017-18 mandate target that DTOCs should equate to less than 3.5 per cent of all NHS beds by September 2017. Neither social care nor the NHS met the requirement.

Moreover, the number of DTOC beds rose month on month between December and January. According to NHS England’s most recent published data, DTOC beds rose by a couple of hundred to 4,913.

It was the first rise since August (though it is worth noting the 23 per cent reduction on January 2017). DTOCs usually rise between January and February. If there’s a reason to be concerned, it’s the end of the trend defying performance over the previous 10 months or so.

Predictions are a mug’s game but I would expect a further rise occurred in February given the adverse weather, high levels of flu, norovirus and general acuity.

So, while the past year has been promising: it feels like battles rather than the war have been won as regards DTOCs.

On the subject of battles, resolution of the ongoing feud between local government and the NHS would appear a pre-requisite if there is to be a genuinely integrated drive to robustly address the huge number of beds still filled by patients who are medically fit for discharge, even if a good start has been made.

A bit of argybargy between NHS England and the LGA doesn’t preclude good local council NHS relations, but it certainly sets an adversarial tone and feeds into national level policy.

By James Illman, correspondent at Health Service Journal



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