Delayed transfers of care
For most people, NHS treatment will be successful and they will return home. However, some people will need to be transferred to other forms of care. Effective discharges require joined-up working, otherwise there can be delays in the transfer of care.
The Community Care Act 2003 introduced responsibilities for the NHS to notify social services of a patient’s likely need for community care services on discharge, and to give 24 hours’ notice of actual discharge. It also requires local authorities to reimburse the NHS for each day an acute patient’s discharge is delayed where social services are solely responsible for that delay.
A delayed transfer of care from acute or non-acute care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready for transfer when:
a. A clinical decision has been made that the patient is ready for transfer; and
b. A multi-disciplinary team decision has been made that the patient is ready for transfer; and
c. The patient is safe to discharge/transfer.
There is an expectation that delays to transfers of care will be minimised through the following steps:
• Discharge planning begins on admission to hospital or in the early stages of recovery
• There are no built-in delays in the process.
• Services will jointly review policies and protocols around discharge and have systems and processes for assessment, safe transfer and placement, as part of their capacity planning.
These steps should be guided by good professional practice and safe, person-centred transfers.
The focus of this data set is to identify patients who are in the wrong care setting for their current level of need. The number of patients delayed is a proxy for all patients as it is a snap-shot view determined by the number of patients who had a delayed transfer of care at midnight on the last Thursday of the reporting period. These figures are being collected for all adults (over 18s) in SITREPs.