UTOCs – Unnecessary Transfers of Care
Frazer Anderson is Honorary Secretary of the BGS and a Consultant in Community Geriatric Medicine in East Hampshire. After 20 years as a clinical academic in Southampton he returned to full-time clinical practice in 2016. He has worked across a range of fields including osteoporosis and fracture prevention, comprehensive geriatric assessment and undergraduate education. He previously served on the BGS Research and Academic Development Committee and as Abstracts Editor of Age & Ageing.
One of my least favourite moments of my otherwise very enjoyable MDT meeting is when we come to discuss the new admissions on our rehab ward that week. There are two types of transfer which seem to be increasingly common. Let’s call them Mr Smith and Mr Jones…
“Tell me about Mr Smith,” I say.
“Well, he’s been sent to us from the Big Friendly Hospital for rehab,” says my Ward Manager.
“What’s he like?”
“He’s up all night, his falls alarm is going off constantly, he’s incontinent and he won’t eat or drink. His wife came in yesterday and he didn’t recognise her.”
“Do we know what’s supposed to be wrong with him?”
“Has he got a UTI?”
“Of course not.”
“Is that JOHN Smith?” pipes up our social worker, “Because if it’s him, he was on my BFH colleague’s caseload for Nursing Home placement last week, but he was closed because he wasn’t Medically Fit”.
“Well, he was declared MFFD on the transfer papers,” says my GP colleague who sees the new admissions and provides most of the medical care. “And there’s no mention of delirium or dementia. His bloods are OK and there’s no sign of active infection.”
“Can we get him to a Nursing Home now he’s here?”
“Well… not really. He checks in on the Continuing Health Care checklist so needs a full CHC application. As he is now, he’s also far too cognitively impaired to consent to that – or anything else we could do to help him – so he needs a DOLS referral urgently. I tried ringing them earlier but they’re all on a training day.”
“So we’ve got a man who we can’t do much to help who’s going to be here for weeks. <Sigh…>”
“Now how about Mr Jones?“
“He’s also here for rehab following multiple falls but he’s mobile, orientated, fit as a flea and just wants to go home.”
“Safe transfers, maybe minimal supervision of one when he’s tired because of the bruising around his knee. Needs help with washing and dressing, but that should only be for a week or two. Says he’s only ever fallen twice, tripped over the cat” adds the physio.
“Lives with his wife in a bungalow, lots of adaptations done previously when she had a hip fracture. I think he was OT Complete at transfer but the paperwork didn’t come with him” says the OT. “As far as I know he was just waiting for a small care package via the Early Supported Discharge team.”
“PETER Jones? ESD were due to start his care package on Monday, just a once-daily in the mornings for two weeks.”
“Can we hook him up with that care package and get him home anyway?”
“No, ESD have to give priority to clients in the Big Hospital so they closed him when he was transferred. I’ll apply again today but he’ll be at the back of the queue.”
“How long will that take?”
“Two weeks if we’re lucky.”
Mr Smith, Mr Jones and very many others like them are examples of a phenomenon which we all recognise but which no-one has put a (printable) name to yet: the UTOC, or Unnecessary Transfer of Care. These unfortunate people are being moved around the system at no benefit to themselves and often at great distress to them and their relatives. UTOCs waste money and more importantly the precious resource that is staff time. It makes no sense. So why is it happening?
One of the more intractable problems besetting our health and social care system is that every organisation has its own priorities. For all the fine words about patient-centred care the most urgent priorities usually boil down to throughput and resource management. Whatever has been agreed about appropriate patients for transfer between services, when it comes to a Friday afternoon with the Big Hospital on Purple Alert and ambulances backed up outside the Emergency Department then an “appropriate patient” becomes anyone who isn’t actually on a ventilator or radioactive. The fact that this then reduces rehab capacity or leads to readmissions is simply not the problem of the harassed, exhausted Bed Manager whose job depends on making space for the patients piling up in ED before the TV news crews turn up.
Of course everyone in every part of the system understands that this doesn’t make any sense and almost all organisations are trying to do something about it. The problem is that very rarely is anyone taking a whole-system perspective, so each effort crashes into the wall of the next silo along. For example, when I was working at a Big Hospital myself, we had a major push to ensure that patients were signed off Medically Fit as soon as possible. This tied up lots of resources but the project was a great success as judged by improvement in time-to-MFFD. However as there was no change in downstream capacity length of stay did not change at all – we had just moved people from one delay category to another. What we actually needed most at that time was more engagement with Adult Social Services but our lovely hardworking Social Workers had just been taken out of their hospital base (and our MDT meetings) so we hardly ever saw them any more.
What can we do about this? First and foremost, make some noise! We’re the second-largest medical specialty, our patients are the most numerous in most hospitals and also the ones who suffer most from delays. For those of us based in the community, there’s huge opportunity because the sector is underdeveloped and everyone accepts that things need to change. Even so, it’s easy to be overcome with a kind of “learned helplessness”, the feeling that whatever we say or do nothing will happen and, yes, there is a heck of a lot of what von Clausewitz called “friction” working against attempts to make things better. Of course, there’s “no money” but there’ll never BE any money if we all say “after you, Claude” as the shiny specialties demand their new staff/buildings/kit.
Within the BGS there are many, many people who have found ways to improve the care of their patients and NONE of them had the tools and resources handed to them on a plate. Let’s make a point of talking to each other, learning what works and then going back to our workplaces and making an evidence-based fuss until we change things for the better.