Delayed transfers of care

A delayed transfer of care occurs when a person is in hospital and is ready to leave the hospital to move to another setting but is still occupying a hospital bed. A patient is ready for transfer when:

  • a clinical decision has been made that the patient is ready for transfer and
  • a multi-disciplinary team decision has been made that the patient is ready for transfer and
  • the patient is safe to transfer.

A person's transfer from hospital can be delayed for a number of different reasons including waiting for further assessments, waiting for suitable accommodation in order to facilitate a safe discharge or if individuals and their family require more time to make further choices.

Delayed transfers of care are recorded as part of the Adult Social Care Outcomes Framework. This records weekly the total number of delayed transfers of care and the number of delays which are attributable to social services.

What do we know?

To achieve the most efficient use of resources and to maximise the wellbeing outcomes for residents, people recuperate best at home in an environment familiar to them with support provided to maximise their independence.

People staying in hospital when they are fit for discharge can create a capacity pressure in terms of bed availability, especially for emergency admissions which places additional pressures on health and social services economy.

Nationally long term trends of delayed transfers are declining. Official statistics in 2008 showed 5,330 patients per day faced a delay in any one month, by 2012 this had reduced to just under 3,990 which was a decrease of 5% from 2011 (Kings Fund, 2013).

Facts, Figures, Trends

Locally on average there are approximately 50 referrals per month made to Slough Adult Social Care Hospital Social Work. Of which there are ongoing referrals to RRR (Recovery, Rehabilitation and Reablement) or referrals to Adult Social Care panel for placements. Hospital Social Work do in-reach to wards and work alongside the NHS Discharge Team, however most referrals are made via a Section 2 referral to Social Work for Discharge arrangements.

Latest benchmarking data released shows that the rate of delayed transfers of care in Slough is similar to the England average. Figure 1 shows the trend in delayed transfers which have been generally decreasing since 2010/11

Figure 1. Total delayed transfers of care in Slough

Figure1

National & Local Strategies (Current best practices)

There is pressure on hospitals to facilitate safe and timely discharges out of Acute and Community Hospitals and there are many performance measures attached required to monitor the frequency of this occurring through the Adult Social Care and NHS Outcomes Frameworks.

When the patient is ready to leave hospital a clearly recorded discharge plan will outline the services the individual requires and agree which organisation is responsible for arranging them. The latest guidance makes clear that the NHS body in question has discretion over whether to seek reimbursement from the local authority for each day a patient’s discharge is delayed.

The Better Care Fund (BCF) was created in 2013 and provides a single pooled budget to incentivise NHS and local government to work more closely to improve wellbeing through integrated care. The programme involves payment for performance based on indicators such as delayed transfers of care among others.

What is this telling us?

Slough services are performing well in terms of ensuring that people return to their homes or care homes in a timely fashion after admission to hospital.

What are the key inequalities?

Though analysis of national data on delayed transfers of care suggests that there are a variety of reasons for delays, there is no evidence to suggest that any particular group suffer greater risk of delayed transfer than another.

What are the unmet needs/ service gaps?

Slough services are currently working well to minimise delays in transfer of care, however, there is a relative gap in working to prevent admissions which is a priority for the adult social care reform programme.

Recommendations for consideration by other key organisations:

  • To continue working towards integration of health and social care
  • To continue to explore joint health and social care personal budgets
  • To continue to develop models to enable people to take more responsibility for their own care and support with the assistance of council, voluntary sector and NHS partners
  • To make more effective use of local assets and to develop community resilience
  • To support people through the pathway by providing clear and concise information and advice in a seamless manner

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