Care & Health 24th August 2018 - 5 min read

Delayed! Optimising the Care Pathway to address DToC

By Joni Lindes

Delayed Transfer of Care (DToC) is a phrase most health practitioners have heard all too often. Most patients, in actual fact, seem to hear it all too often. It is defined as the period of continued hospital stay after a patient is deemed medically fit to leave hospital but is unable to do so for non‐medical reasons. These patients are essentially in the wrong place at the wrong time. In June 2017, the average DToC rate was at 4.9%. This means that one in twenty hospital beds across England were occupied by somebody who did not need to be there and probably did not want to be there.

Sitting in hospital is hardly what most patients view as ideal. Increased time in hospital increases the risk of infection by 5%. It can increase muscle ageing. In older patients, one day of bed rest is equal to around one year of muscle ageing.


Not only does it have a negative impact on their health, but it also drains hospital resources. A hospital bed is much needed and appreciated in acute cases, but if not necessary then why are most patients still in hospital?

Bed occupancy levels should ideally be under 85%, yet, in 2017, occupancy rates reached over 89%. We are aware of the constant pressure on NHS resources, which is why the NHS is committed to reducing DToC rates via the guidance of the Better Care Fund.

The Better Care Fund, along with the councils, NHS Trusts and CCGs, carried out an initial two week assessment in May to July 2017. They reviewed over 130 cases with over 2899 beds across the Sheffield, North Cumbria and Fylde Coast areas. They discovered that, out of 501 total delayed beds, 281 of the beds were reported as DToC.

Across all systems, the average number of delayed beds was 17%, yet only 10% were reported as DToC.

How do we decrease DToC?

In order to decrease DToC we need to first understand why each delay is happening. Healthcare data on a patient’s stay is collected and available the moment they enter the hospital. We can use dashboards to define this data in the form of a care pathway to assess the patients journey while bringing delays and their causes to the surface.

Why were patients kept waiting?

In the two week assessment conducted by the Better Care Fund, four main reasons for delay were discovered:

1. Patients were waiting for a placement

160 people were waiting for a placement amounting to 36% of all delays.

Of this number, 16% were waiting for an assessment, 14% were waiting for therapy, 3% were there due to a delay in a patient or family decision, yet only 3% were there due to their best interest.

The chief reason why these delays are occurring is that the system is built around acute-based therapy and service. Once there is no immediate need for the service, a lack of clear communication and ownership for patient progress occurs.

In order to aid better communication around this service, we can use data dashboards to intelligently assess a complete view of each care point along the pathway and not only when the patient is in an acute setting. Healthcare providers need to gain a shared understanding achieved through clear communication and ownership taken for each step along the pathway.

2. Patients were waiting to go to either an immediate nursing or residential bed setting.

166 patients were found to be waiting to be transferred to an intermediate, nursing or residential care bed but instead found themselves stuck in the hospital setting. They made up 33% of all patient delays and 25% reportable DToC delays.

The root of this problem was mainly due to a reluctance from decision makers at the frontline to take a risk on the patient’s care. We believe that we can overcome this dilemma by using data to predict patient outcomes. Already, we have applied this to social care settings where we were able to use a model to predict educational outcomes in the Essex Data Programme.

Once better informed, front-line staff can be empowered to make decisions going forward. Most patients could have gone on to home care instead of being stuck in residential or nursing homes. Assessments can be undertaken out of hospital after the patient has gone through a period of re-enablement. Better communication of the rate of progress can assist services with an understanding on next steps to take.

3. Patients were waiting to go home with extra support

113 patients assessed in the study were discovered to be waiting to go home with support. These patients accounted for 23% of all delays and 18% of the reportable DToC delays. Patients were waiting on domiciliary care (11%), extra equipment (13%) or reablement processes (9%).

Reablement, as a process, will help patients to accommodate their illness by learning or re-learning the skills necessary for daily living. Every day spent in a hospital setting further drives them away from the processes associated with daily life.

“The evidence so far strongly suggests that a period of home care reablement can reduce the subsequent use of home care services and that, for some people, these benefits may last for a year or more,” said Caroline Glendinning of the Social Policy Research Unit in the University of York.

The benefits of reablement get crumpled once a patient spends too long in bed in the hospital setting. The Better Care Fund study found that reablement services were often not optimised due to decreased capacity for it.

Through a thorough data-driven assessment of the patient and their journey plus the data pooled from the hospital resources, we can improve the effectiveness of reablement by allocating the right resources to the process at the right moment.

4. Other reasons for delay

Around four patients and 8% of total delayed beds were waiting for other reasons.

On the road to a better Care Pathway

The root causes of DToC is mainly due to a lack of capacity coupled with a lack of communication. Data can be used to address both these concerns. Even though we cannot change the resources allocated to healthcare, we can learn how to better direct them. Through better communication and increased access to the patient’s journey we can set them on a care pathway that will see them home and recovered – leaving out unnecessary waiting periods.

“A single set of evidence is needed, showing where people are waiting and a shared understanding of the underlying causes, based on robust, detailed evidence, “ The Better Care Fund, 2017.

Data can be that set of shared understanding. We currently use dashboards to pinpoint areas that need the most attention and may have been forgotten by previous healthcare services. Once we have full insight into the system we can use this to address each care point and move patients down their path to full recovery.

Joni Lindes
By Joni Lindes
5 min read

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