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Simon Bottery: Bullying and stoking fights will not help to cut DTOCs

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The ongoing row about the better care fund and delayed transfers of care has flared again during a debate in the House of Commons. 

Former shadow care minister Liz Kendall (Lab) said Leicestershire CC feared it could lose £22m in fines after it was judged to be one of the poorest performers in reducing delayed transfers of care (DTOCs).

The current care minister, Jackie Doyle-Price, did not like the word “fine”, preferring to say the government “reserved the right to review allocations” but, as current Labour shadow Barbara Keeley observed, the clear implication was that this review would be downwards and not upwards.

So what lies behind this tough stance with councils? The catalyst was a letter from communities secretary Sajid Javid and health secretary Jeremy Hunt threatening to withdraw funding next year from 32 local authorities deemed to have made insufficient progress in reducing DTOCs.

Yet if seeking to allocate blame, the current figures on delayed transfers present a more mixed picture than you might think:

  • Overall, delayed days are down year-on-year for both July and August 2017, the first year-on-year monthly reduction since January 2014.
  • The NHS, not social care, continues to be responsible for most delays, though the number of days for which it is responsible has fallen, from 110,321 in August 2016 to 100,234 in August 2017.
  • The number of days for which social care is responsible has risen slightly during that period, though the rise has levelled off in recent months after peaking in March this year.
  • There is wide regional variation in performance but, as we have previously shown, this applies in the NHS as well as in social care.

The source of the dispute, then, goes back further. The extra £1bn of better care fund money promised to councils this year was intended not just to reduce delayed transfers but to address the existing pressures on social care services and to support providers, who are facing additional costs, particularly from the introduction of the national living wage. However, exactly how the money was used was to be agreed locally and at the time the HSJ quoted a senior NHS source encouraging hospitals to “get lippy” in securing the money to reduce delayed transfers. This was probably prompted by the tough mandate the NHS received from the government to reduce the proportion of the total bed days lost to delayed transfers of care to 3.5%by September.

As the year has gone on it has become clearer this target will not be hit. The situation is also affected by what is now happening at the ‘front door’ of hospitals, with month-on-month emergency admissions from A&E running at 2.5% higher than in 2016. So hospitals are filling up and, as we outlined recently, the UK has fewer acute hospital beds per 1,000 inhabitants than other advanced countries and very high levels of occupancy. Even a small rise in DTOCs can have big consequences when there is so little slack in the system.

It is easy to believe that NHS England, aware it is likely to miss its DTOC target, worried that hospital admissions are rising and could rise further this winter, is continuing to use whatever levers it thinks it has available to reduce DTOCs, mainly the better care fund money.

Councils, however, do not quite see it that way. The Local Government Association describes the row over delayed transfers as “hugely unhelpful” and says it is “deeply concerned that the national narrative is seeking to attribute blame for DTOCs solely to adult social care”. They point out councils are already planning to spend around one third of the extra £1bn on DTOCs, which they argue is a reasonable amount as only a fifth of new requests for social care last year related to people in hospitals.

And even if they were to allocate more money to DTOCs, would it make a significant difference in the short term? Perhaps not, as delayed transfers are more likely to be the consequence of system failures rather than the actions of individual parties, whether in social care or the NHS. Demonstrating this are the recent Care Quality Commission reports on health and care systems in Cornwall and Sutton.

The report on Cornwall, which has high delayed transfers, describes systemic problems: “The systems in place for discharging people… were confusing, despite the efforts of frontline staff and the onward care team. The processes and direction provided to them to manage the DTOCs were incomplete, duplicated and not aligned to an agreed operational plan or strategic vision for inter-agency working.”

The CQC recommendations are around systems leadership, inter-agency working, staff and customer engagement and management accountability, recommendations that will take some time to yield results.

For Sutton, which has much lower DTOCs, the findings were that collaborative working and a listening culture had “improved care for older people in care homes in order to both reduce hospital admissions and to enable rapid and safe discharge from hospital”.

These findings highlight the need for the NHS and social care to work together to resolve issues like DTOCs. Actions that might threaten partnership working, such as stoking a dispute about funding or behaving in a way that has been described as “bullying”, are unhelpful as winter approaches and collaboration surely becomes even more essential.

Simon Bottery, senior fellow – social care, The King’s Fund

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