24/10/2019 - Permalink

Shropshire Council exceeds Delayed Transfer of Care (DToC) target

Related topics: Adult social care / Health / Partner organisations

Shropshire Council has again exceeded its Delayed Transfer of Care (DToC) target in ensuring that residents don’t stay in hospital longer than they need to.

Current figures (for August 2019) show the number of delayed discharges of care (DTOC) across Shrewsbury and Telford hospitals, that was attributed to adult social care, was just three days, one of the lowest reported across the UK.

The Delayed Transfer of Care figures, produced by NHS England, show that during the current year the monthly number of delayed bed days has reduced. Both the council’s adult social care services and NHS partners in Shropshire have seen a sustained long-term improvement in the reduction of delays.

Shropshire's Integrated Community Services team

Shropshire’s Integrated Community Services team

Shropshire’s Integrated Community Services (ICS) team, jointly run by Shropshire Council adult social care and Shropshire Community Health NHS Trust, provide short-term support for patients who are ready to leave hospital. The team also work closely with partner organisations to identify people who need support to avoid an admission to hospital in the first place.

Tanya Miles, Shropshire Council’s assistant director – adult social care, added:

“Our social care teams work extremely hard to support people to be discharged from hospital as soon as they are well, and help people avoid hospital admissions. We are seeing their hard work being paid off by the month by month reduction in DToC figures attributed to adult social care.

“We continue work with our health and social care partners to further explore possible solutions to help reduce the number of patients remaining in hospital and returning home, which we know they prefer to be.

“I would like to say a huge thanks to all those involved who I know have worked extremely hard to ensure that people return home from hospital as soon as possible. This is a great result from the team.”

Steve Gregory, Director of Nursing at Shropshire Community Health Trust, added:-

“It is important that patients are cared for in the most appropriate setting for their needs.

“These figures relate to a small handful of patients with complex needs that must be met so that they can be discharged or transferred safely. Sometimes it takes longer than we would like to enable the right support or service to be available.

“We work with others within the Shropshire care system to make sure any delay is kept to a minimum and, where possible, we look for learning or system changes that would help in similar situations in future.”

Shropshire Council and health and social care partners across Shropshire have introduced a number of initiatives which have contributed to the reduction in DToC figures. New programmes and initiatives to help patients return home sooner, or support those to avoid hospital admission, include:

START team

Due the success of Shropshire Councils START (Short Term Assessment and Reablement Team), the service is now being further developed and extended to support DToC and admission avoidance.

The service supports people to regain lost skills, learn new ones, and generally increase their ability and independence. START offers a short-term assessment and re-enablement service (maximum six weeks) to people who are discharged from hospital and to prevent admission to hospital. START work with people, in their own home utilising a person centred, strength and asset based approach. 

Over 60% of people who use the START re-enablement service are discharged without the need for ongoing services, and also leave the service faster between 1 and 14 days, compared with the independent market comparison. This shows that the START service is faster at taking people through a re-enablement programme, provides better outcomes, and leads to less dependence when compared to the market

Bespoke night time support (Two carers in a car) – This pilot scheme involves two carers who can travel to any household within the Shrewsbury area to provide support between 10pm and 7am. This support may be assistance for toilet care, to getting into bed at a later time than when regular carers are available, reassurance if just home from hospital, or as an alternative to a hospital admission where night support is required. Request for placements are often due to night support being required, but many people do not need this throughout the whole night. This scheme enables care support to be provided to a number of people throughout the night.

Extra care units – Where additional support is needed but can’t be provided within the person’s home, the council has commissioned four new ‘independence’ units located within a local housing development. These units are individually self-contained, where couples or single people can live, and where they can continue to receive therapeutic and care support prior to, and during, their transition when moving back to their own home. These units will be particularly beneficial for those discharged patients not able to return home from hospital. They will provide people with the environment where they can continue to regain and improve their ability to live in their own home, which for many people is what they wish to achieve, and evidence demonstrates is difficult to achieve if admitted to residential placements. This will allow people who require a period of enablement in an environment where they can be accompanied by their partner and receive further support to develop their independence skills.

Let’s Talk Local (LTL) hub – There is also the hospital-based ‘Let’s Talk Local’ hub, which will offer information and advice around visiting times for people who are supporting friends, neighbours, and family members who are in hospital.

SaTH Frailty Intervention Team

A frailty service at the front door of Royal Shrewsbury Hospital was launched to reduce admission and reduce lengths of stay for patients aged 75+. Working together with Shropshire CCG, Shropshire Community Health NHS Trust and Shropshire Council, the new team combines health and social care professionals. It is a fast track service to get frailer patients over 75 quickly assessed, treated and discharged safely back to their own homes. This service has also been extended to PRH.


SaTH2Home was launched to provide rapid, same-day domiciliary care for patients awaiting care packages to start or who require support to settle back to their home. This enables discharge to be facilitated on the day a decision is reached that an individual no longer requires acute care.

Pathway Zero

This is a new pathway being introduced. Pathway zero aims to support discharge from hospital for people whose needs fall below a particular and who may be readmitted without support. The aim is to discharge and support this group of people in their normal place of residence. People going through this pathway will also be offered appointments into one of the existing LTL hubs in the community where they live. 

Red bag schemes

People living in care homes in Shropshire are set to benefit from an innovative scheme to help them receive quick and effective treatment following an emergency admission into SaTH’s hospitals. The “Red Bag” scheme is a national initiative being trialled by health and care partners in Shropshire, including SaTH.

After being successfully implemented in Telford & Wrekin last year, the scheme is now being rolled out to initially four Shropshire care homes, Montgomery House, Isle Court, Holy Cross and The Vicarage in Shrewsbury. Care home residents who may need to attend hospital in an emergency, will be given a specially designed red bag that will not only contain their personal items but important information about their general health and wellbeing.

This information will include any existing medical conditions they have, medication they are taking, as well as information highlighting any current health concerns and important personal details about the individual’s health and wellbeing. This means that ambulance and hospital staff can determine the treatment for the resident more quickly, and provide more immediate, appropriate and effective treatment.

When they are ready to go home, a copy of their discharge summary (which details every aspect of the care they received in hospital) will be placed in the red bag, along with their medication, so that care home staff have immediate access to this important information. 

Further information

What is a Delayed Transfer of Care?

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:

  1. A clinical decision has been made that patient is ready for transfer and
  2. A multi-disciplinary team decision has been made that patient is ready for transfer and
  3. The patient is safe to discharge or transfer.

Adult social care services, as well as acute settings such as hospitals, across England, are expected to maintain or reduce the number of patients who are delayed in such circumstances. The Government has set each organisation a target to reduce the delays of transfers of care. A Delayed Transfer of Care from acute or non-acute care occurs when a patient is ready to depart and is still occupying a hospital bed.