Impact of Urgent and Emergency Care Vanguards on Delayed Transfers of Care in England

Objectives: To assess the relationship between Urgent and Emergency Care (UEC) Vanguards, which include as an aim the integration of healthcare and social care sectors, and Delayed Transfers of Care (DTOC) at Local Authority level in England. Methods: Difference-in-difference and fixed effects panel estimations were used to compare DTOC between UEC partner site Local Authorities with non-UEC Local Authorities employing quarterly data on days of DTOC from Local Authorities in England for the period 2010 to 2017. Robustness checks included employing Ordinary Least Squared (OLS) and synthetic control estimations; differences between the UEC and non-UEC sites were checked prior to the start of the Vanguards. Results: A statistically significant negative relationship was found between UEC Vanguards and DTOC rates that is robust to various specification checks with no indication of UEC participant sites having lower DTOC rates prior to the start of the initiative. Conclusions: UEC Vanguards appear to be associated with 40.5% lower DTOC rates at 1% significance level compared with other English Local Authorities. The empirical evidence indicates a statistically significant impact; however, more research is required to explain the reasons for this relationship.


Background
Delayed Transfers of Care (DTOC) is a term used to describe situations where patients are medically fit to be discharged from a hospital to home or further care settings but the process is delayed. DTOC has attracted increased attention from policy makers and health and social care professionals (1), due to recent increases (2), an estimated £820 million annual cost (3), and delayed hospital discharge has been associated with decreased subsequent participation in activities of daily living, frailty, increased age, high comorbidity, cognitive impairment, and dependency (4)(5)(6)(7)(8)(9)(10).
Attempts to address the costs associated with DTOC have inspired some innovative policy approaches to integrating social and health care over the last few years, including Better Care Fund (11), Integrated Care Pioneers (12) and recently New Models of Care -Vanguards (13). Vanguards set out to help improve integration of services with five different approaches (13):  Acute care collaboration -link local hospitals to improve clinical and financial viability.
 Urgent and emergency care -improve coordination of services and reduce pressure on A&E departments.
 Enhanced health in care homes -improve and integrate health, care and rehabilitation services for older people in care homes.
 Multi-speciality community providers -move specialist care into the community from hospitals.
 Integrated primary and acute care systems -join up GP, hospitals, community and mental health services. This paper examines the relationship between Urgent and Emergency Care (UEC) Vanguards and DTOC rates specifically, since discharge planning from acute care was identified as one of the challenges by the UEC Vanguards (14).
Since DTOC may be directly affected by the effectiveness of communication between health and social care providers, DTOC rates may be a useful proxy for some aspects of integration. DTOC has previously been used as a criterion for evaluating the success of health and social care integration policy initiatives (15).
To date, research related to DTOC is somewhat scarce. Most research considers challenges related to the discharge of older people: appropriate future support, suitable discharge destinations, and how policies are put into practice (16)(17)(18)(19), and how lack of social care supply may increase DTOC (20).
Concerns over the integration of services in general are also considered (21,22). As part of a wider study examining the role of social care in DTOC (23) we examined the link between UEC Vanguards and DTOC rates.  although results with the latter specification were comparable.

Methods
Synthetic control estimations (26)(27) were run as robustness checks, to create a control unit that matched the main characteristics of the treated unit (i.e. derived average of all UEC Vanguard partner sites). This allowed for a more credible prediction of the counterfactual, and was created using characteristics of local authorities that were not UEC Vanguards.

Fixed effects panel regression
Robustness checks Table 2 also presents some of the robustness checks we employed. The findings show there was no statistically significant relationship between UEC Vanguards and DTOC in these alternative specifications that suggests that UEC Vanguard sites did not have lower DTOC rates prior to the start.

Main findings
Our findings suggest that LAs that were part of UEC Vanguards had

Limitations
We cannot claim the relationship between UEC and DTOC to be causal.
There is no publically available information on the criteria of selection into different Vanguards, which might inform explanations and analysis. Further work on specific policies used within UEC Vanguard sites, including qualitative analysis and exposure levels to UEC Vanguards by LA, could help untangle potential reasons for the association between UEC Vanguards and DTOC.

Conclusions
The introduction of the UEC Vanguards seems to be related to significantly

Declarations Ethics Approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This study was funded by the National Institute for Health Research School