Transforming Discharge Processes in Hull & East Riding of Yorkshire
The PSC supported a 75% reduction in the number of long-stay patients delayed in hospital, through an innovative 'recovery-first' transformation approach to discharge pathways.
In an era where healthcare systems face increasing pressures, efficient patient discharge processes are crucial for maintaining optimal care quality and managing resources effectively. Partners in Hull and the East Riding of Yorkshire worked with The PSC to design and deliver a new discharge and intermediate care model. The Discharge to Assess Transformation Programme involved over 100 professionals and 150 patients and carers between January 2023 and March 2024, and saw NHS, local authority, and voluntary sector organisations work in joined up ways to deliver a new, integrated discharge model. This work was since shortlisted for Most Effective Contribution to Integrated Health and Care by the HSJ Partnership Awards 2025.
The Challenge
Hospital discharge is one of the most pressing issues facing the NHS today. In 2023-24, every day around 15,000 people were delayed in hospitals in England after they are medically fit for discharge, accounting for over 17% of the NHS’s bed-base.1 The HSJ recently (October 2025) confirmed our previous estimates of the cost to the NHS of these discharge delays being £2 billion each year (£200m per month)2 - not to mention the knock-on effect on elective recovery, ED performance, ambulance handovers, as well as patient outcomes and experience.
Some improvement can be realised through the introduction of better discharge processes in-hospital (e.g. more patients receiving a same-day proportionate discharge assessment). However, data published by NHS England shows that around two thirds of discharge delays are caused by a lack of capacity in services designed to support people after they have been discharged from hospital. In other words, around 10,000 people are delayed in hospital every day while they wait for support to become available closer to home.3
So, care outside a hospital is key to fixing challenges within it.
What did the partnership do?
The PSC's Transformation team supported Hull and East Riding of Yorkshire with:
- Co-producing a new integrated discharge model, with over 150 patients and carers engaged through surveys, interviews, and focus groups, and workshops attended by 40 professionals from eight organisations thinking in organisationally agnostic ways about how the healthcare system as a whole could deliver the best possible outcomes for patients.
- The introduction of innovative practices generated by the partnership, including: a new discharge tracking system (Optica), with shared access for NHS and local authority partners to ensure one shared version of the truth; a co-located integrated discharge hub at Hull Royal Infirmary, bringing together representatives from Hull University Teaching Hospitals NHS Trust, City Health Care Partnership, East Riding of Yorkshire and Hull City Councils, as well as voluntary sector organisations, enabling faster and better discharge planning in hospital; and an enhanced voluntary sector discharge offer, consisting of three new support services provided by four different organisations, integrated into hospital through new voluntary sector discharge co-ordinator roles.
- Encouraging other organisations to adopt best practice generated from the programme, including sharing learnings with other places within the Humber and North Yorkshire ICS, NHS England’s Intermediate Care, Urgent & Emergency Care and Productivity team, the Discharge Integration Frontrunner Programme through national webinars, and providing practical support and guidance to six other ICSs, including a demand and capacity modelling technique which has been adopted by other systems.
The Results
The outcomes of this transformation are significant - and continue to have an impact today, over a year from the end of the programme. Our analysis on 21+ days length of stay patients, using nationally available data from the NHS on Bed Availability & Occupancy4, demonstrates this:
We have highlighted the key impacts of the programme to date below:
75% Drop in long-stay patients delayed in hospital
The number of long-stay patients (21+ days, a good indicator of those with onward discharge needs) reduced by 75%. This reduces the likelihood of deconditioning and promotes better long-term outcomes for patients.
50% Reduction in discharge delays once medically fit
The average number of days that a supported discharge patient remains in hospital after they become ‘medically fit’ for discharge reduced by half for all patients at Hull University Teaching Hospitals Trust, from ~8 days to ~4 days.
102% Increase in 'Recovery First' intermediate support
Since July 2023, there has been a 102% increase in the number of patients receiving intermediate care support from City Healthcare Partnership, exceeding the target increase of 50%. This means that more patients are having the opportunity to recover and re-able when they leave hospital, promoting long-term independence and resilience.
£12m Forecast Annual Financial Benefit
Financial benefit already realised includes over £499k of funding released for voluntary sector services to provide enhanced discharge and intermediate care support, and an estimated £2.6m saving for East Riding of Yorkshire Council through a reduction in spend on long term packages of care. Full delivery of the new discharge and intermediate care model is forecast to deliver ~£12m of annual financial benefit, through a reduction in discharge delays in acute and community settings, as well as a reduction in demand for long term packages of care. If this success was scaled nationally, the benefits would be greater than £1bn, and even more in terms of better patient care.
Additionally, thanks in part to the impact of this programme, Humber and North Yorkshire ICB is now in the top 1/3 of ICBs for discharge performance, as demonstrated by having ranked in the lowest 1/3 of ICBs for discharge delay spending (as a % of monthly allocation)5.
Learn More
For more insights on improving discharge processes and intermediate care, we invite you to read our related blog on Looking Beyond Hospital Walls for Discharge Solutions and our Getting Discharge Right roundtable. These articles provide further context on the challenges and opportunities in transforming discharge processes across healthcare systems.
For more information on how The PSC can transform healthcare processes and improve patient outcomes, please contact us at hello@thepsc.co.uk
References
1 The PSC Analysis on NHS Bed Availability & Occupancy and Discharge Sitrep, 2023-24
2 £2bn cost of delayed discharges revealed for first time, The HSJ, October 2025
3 The PSC Analysis on NHS Discharge Sitrep, 2023-24
4 The PSC Analysis on NHS Bed Availability & Occupancy Sitrep, 2022-25
5 £2bn cost of delayed discharges revealed for first time, The HSJ, October 2025