When no single organisation owns the problem: Hull and East Riding take control of discharge
Partners in Hull and the East Riding of Yorkshire achieved a 75% reduction in long-stay patients delayed in hospital, by treating discharge as a shared problem for the whole place to solve, not a target for the hospital alone.
In an era where healthcare systems face increasing pressures, the places best placed to fix discharge are rarely the hospitals themselves. Hospital discharge sits at the seam between the NHS, local government, and community and voluntary organisations, and it is that seam, not any one institution, that usually fails. NHS, local authority, and voluntary sector partners across Hull and the East Riding recognised this and chose to design a new discharge and intermediate care model together, as one system, rather than as separate organisations each optimising their own piece of the pathway. The PSC supported this work. The Discharge to Assess Transformation Programme involved over 100 professionals and 150 patients and carers. It has since been shortlisted for Most Effective Contribution to Integrated Health and Care at the HSJ Partnership Awards 2025.
The challenge
Hospital discharge is one of the most pressing issues facing the NHS today, but it is rarely an NHS problem alone. In 2023 to 2024, around 15,000 people were delayed in hospitals in England every day after they were medically fit for discharge, accounting for over 17% of the NHS's bed base.1 The HSJ recently (October 2025) confirmed our previous estimates that these delays cost the NHS £2 billion a year, or around £200 million a month.2 The knock-on effects reach elective recovery, ED performance, and ambulance handovers, as well as patient outcomes and experience.
Some of this can be solved inside the hospital, through better same-day discharge processes. But NHS England data shows that around two-thirds of discharge delays come from a lack of capacity in the services that support people once they leave hospital: home care, community beds, reablement. That capacity sits with councils, community providers, and the voluntary sector, not with hospital trusts. Around 10,000 people are delayed in hospital every day simply waiting for support to become available closer to home.3 Fixing what happens inside a hospital depends on decisions made well outside it, which is why this had to be a whole-place effort rather than a hospital-led one.
What the partnership did
The PSC's Transformation team supported Hull and East Riding of Yorkshire's health and care partners to:
- Co-produce a new integrated discharge model, owned jointly across organisations. Over 150 patients and carers were engaged through surveys, interviews, and focus groups, and 40 professionals from eight organisations came together in workshops to think about the system as a whole rather than their own organisation's slice of it.
- Build shared infrastructure rather than separate ones. This included a discharge tracking system (Optica) with shared access across NHS and local authority partners, so the system worked from one common picture rather than several partial ones; a co-located discharge hub at Hull Royal Infirmary bringing together Hull University Teaching Hospitals NHS Trust, City Health Care Partnership, East Riding of Yorkshire and Hull City Councils, and voluntary sector organisations under one roof; and an enhanced voluntary sector offer of three new support services, delivered by four organisations and embedded in the hospital through new voluntary sector discharge coordinator roles.
- Put what they learned into other places' hands. The partnership shared its approach with other systems in the Humber and North Yorkshire ICS, with NHS England's Intermediate Care, Urgent and Emergency Care and Productivity team, and through national webinars with the Discharge Integration Frontrunner Programme. It also gave practical support and guidance, including a demand and capacity modelling technique later adopted elsewhere, to six other ICSs.
The results
The outcomes of this work are significant, and they are still being felt more than a year after the programme ended. Analysis of patients with a length of stay over 21 days, using nationally available NHS bed availability and occupancy data,4 shows the scale of the shift.
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.
Humber and North Yorkshire ICB is now in the top third of ICBs for discharge performance, ranking in the lowest third for discharge delay spending as a proportion of monthly allocation,5 a result built on shared ownership of the problem rather than any single organisation's performance.
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 explore the wider case for treating discharge as a whole-system, whole-place challenge.
For more information on how The PSC can support places to take ownership of complex health and care challenges, 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