Delayed transfers of care

Delayed Transfers of Care of Acute and Non-Acute Patients

Definition of a Delayed Transfer

A delayed transfer of care from acute or non-acute (including community and mental health) 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 clinical decision has been made that patient is ready for transfer AND

  • A multi-disciplinary team decision has been made that patient is ready for transfer AND

  • The patient is safe to discharge/transfer.

A multi-disciplinary team should be made up of people from different professions, including social workers where appropriate, with the skills and expertise to address the patient’s on-going health and social care needs. If there is any concern that a delay has been caused by the actions or inactions of a Local Authority, they should be represented in the team. The way that the team is organised and functions is fundamental to timely discharge and to the patient’s wellbeing.

Where delays occur for people of no fixed abode, the crucial issue is to identify the local authority responsible for providing them with care and support services. For example, if they are admitted to hospital from a public place then that place should be used to identify the responsible local authority. For asylum seekers or other patients from overseas, they should be listed under the local authority in which they currently reside. It is the responsibility of the local authority to decide whether they are eligible for social services.

Medically Optimised

To help manage patient flow more effectively, some NHS organisations collect data on the number of patients for whom a clinical decision has been made that they are ready to transfer. A number of terms are used, including ‘medically fit for discharge’ ‘clinically optimised’ or ‘medically optimised’. It is important to remember that ‘medically optimised’ is not the same as a delayed transfer of care.


The determination that a patient is medically optimised is from a medical perspective only, and is a decision made by the consultant or team who are responsible for the patient. The patient has not had a multi-disciplinary team decision at this point and may need further therapy or social care in-put prior to such a decision being made, so is not a reportable delay.
‘Medical optimisation’ is the point at which care and assessment can safely be continued in a non-acute setting. It is a decision that balances the acute care requirements of the patient, the typical desire of individuals to return to their home environment at the earliest opportunity, the potential harm associated with staying in hospital and the needs of other more acutely ill patients. Too often, early discharge is seen as ‘freeing up a bed’ rather than acting in a patient’s best interests to move them swiftly to a safer, more familiar environment that will encourage supported self-management, speedy recuperation and recovery, and have them feel better.


All staff must understand that there is recognition that patients may still have on-going care and assessment needs (e.g. therapy or social care assessment), but that these needs can and should be met in the community.


Wokingham Borough Council has entered into an agreement with local Clinical Commissioning Groups and hospitals, under the Better Care Fund scheme, to minimise the potential for delayed discharges through local schemes such as “hospital at home”, step-down beds in nursing care and a more integrated intermediate care/re-ablement service.

Intermediate care and short term reablement programmes form a key part of improving the transfer of people in and out of hospital. It formed part of the National Service Framework (NSF) for Older People, which was itself aimed at bringing about faster and more integrated care for older people by building stronger relationships between health, local councils, the private sector and older people themselves. This work has been developed further through the Better Care Fund.


Further integration of health and social care services is a key theme within the Health and Social Care Act 2012, which includes the establishment of Health and Wellbeing Boards in each Local Authority area. Wokingham Borough Council and the NHS are working to ensure that intermediate care and short term reablement services are better integrated and work more effectively at maximising people’s independence.

Wokingham Borough has a dedicated team which undertakes the assessment of people in hospital.  This team works closely with hospital staff to ensure a safe and timely discharge of people back to their homes or other appropriate care settings. The service also provides information and advice for people not wishing to access local authority help, or may make a referral to the Short Term Assessment and Reablement Team, which aims to help people regain, or maximise, their levels independence through specialist short term programmes of support.


Delayed discharges have a high profile nationally, especially when discussing hospital Accident & Emergency (A&E) performance. Many believe that older people waiting to be discharged to residential/nursing homes, or back to their own home with additional support, are “blocking” hospital beds which some A&E patients need admitting to. These delays are frequently due to a lack of care capacity elsewhere in the system, both in NHS and private provision. Although having good performance in minimising delayed discharges, like most local authorities Wokingham experiences fluctuations in its delayed discharge performance; this is mainly linked to lack of capacity in the wider care system. Very few discharges are delayed while patients wait for a formal social care assessment.

The Adult Social Care Outcomes Framework (ASCOF) is a national publication from the Department of Health which can be used to compare the performance of local authorities with responsibility for Adult Social Care. The data for 2014/15 shows that Wokingham had a high total number of delayed discharge days during the financial year, although the number attributable to the local authority (social care) was close to the English average.


Figure 1 - Delayed transfer of care per 100,00 population (all delays)


Average daily rate of delayed transfers of care for NHS Organisations in England, acute and non-acute, per 100,000 population aged 18+, by Local Authority with Social Services responsibility, England, 2014/15.

Delayed transfer of care

All Berkshire authorities are above the national average for the total number of days delayed discharges per 100,000 population.

Figure 2 - Delayed transfer of care per 100,000 population (attributable to Social Care and both)

Average daily rate of delayed transfers of care for NHS Organisations in England, acute and non-acute, per 100,000 population aged 18+, by Local Authority with Social Services responsibility, England, 2014/15.

Delayed transfer of care social care

Wokingham is just above the national average for the number of days delayed discharges attributable to social care, per 100,000 population.


Figure 3 - Days metrics

Delays in care acute

No non-acute data is available for July 2015


Figure 3 shows that most delays occur in acute settings, which fits well with the higher than average number of delays due to hospital/NHS reasons.


Figure 4: Day metrics showing delays in Social Care, NHS and both combined

Transfer of care daily metrics

No non-acute data is available for July 2015


The peak delays were in June, a time when historic trends would expect fewer delays. Nationally it has been suggested that “winter pressures” in A&E are being replaced by a consistent high demand for help, which feeds through to increased delays in discharge. The above graph supports this view.


Looking at the figure 5 we see that there is a peak of delays in June due to “family choice” and “awaiting nursing home placement”, both of which suggest a lack of capacity/choice locally for nursing provision in the private sector. The capacity issue is also highlighted for delays for patients “awaiting care package in own home”.


Unfortunately full data is not available for July, so we cannot see if the trend continued to the following month – linked to known problems in accessing care packages immediately before major holidays when staff availability can be problematic.

Figure 5: Reasons for delays

Non-acute data

No non-acute data is available for July 2015


Minimising delayed transfers of care is a key determinant of the effectiveness of joint working across health and social care. Joint working benefits both organisations financially and improves a patient’s experience and outcomes.


Wokingham Borough has performed well in this area over recent years, but a sustained focus and effort are needed to maintain this performance with the increasing numbers of people now coming through the care pathway. Historically pressures have only been high through periods of extraordinary peaks in activity (for example winter pressures), but this pressure now appears to be sustained throughout the year.


Those most affected by delays in discharge are older people who need care and support arrangements at home or in a residential/nursing care setting.


Staying in hospital too long can increase older people’s vulnerability to medical risks and give them a long term loss of confidence in their ability to live safely in their own home.

Realise the opportunities of integrated working, especially those brought about by Better Care Funding to reduce the number of delayed transfer of care.