Skip to the content

Rebuilding the care pathway from hospital to home



Industry voice: If delayed patient numbers are not to increase still further, care and support teams need to work as one around the needs of the patient – regardless of organisational and technological boundaries, says Simon Williams, director at IEG4

As discussed previously, hospital patients in England are spending 1.15 million unnecessary days in hospital due to delayed transfer of care (DTOC) on discharge. The cost to the country is enormous – £900 million a year according to Lord Carter – and the human impact is unquantifiable. Yet that could just be the tip of the iceberg: the National Audit Office estimates the ‘true’ figure for DTOC could be as much as 2.7 times higher than stated.

However, our co-discovery work suggests that a common approach to patient assessment and communication of discharge needs could help improve performance in up to 90% of these cases.

Cultural resistance to common standards and processes plus technical barriers have long stifled progress and collaboration across sectors. But these are easing. For example, a culture of paper based administration prevails in the NHS, and until recently some GP practices would not even accept discharge notification in a digital form; but they will be forced to accept an electronic discharge letter by statute later this year. 

There is also a widely perceived fear around data sharing and privacy. But in reality, in the context of hospital discharge, the data you really need to share from patient records is pretty minimal. You’ll certainly need information to be pragmatic - that is, aimed at informing the stakeholders with roles to play in the support team - but that does not constitute an entire medical history, or, necessarily hugely sensitive data. 

We must also realise that data for discharge is the citizen’s data - to share if they so wish with stakeholders who can help them - and not the NHS’s data to keep from others. This may require education and cultural change but existing data protection laws do not prevent it. Indeed, the Information Commissioner’s Office lead policy officer recently stated that it recognised the benefits of sharing initiatives and that, if approached correctly, the Data Protection Act “should be an enabler”, not a barrier. Remember, the ICO has never fined an organisation for sharing data incorrectly as it ‘sees the benefits and wants to spread good practice’.

To improve the status quo and improve hospital discharge efficiency, a joined up approach between agencies is essential. We believe that one way to tackle this is to work on an outcomes based approach using IEG4’s Semitae solution for multi-agency assessment and outcome monitoring.

Semitae - Latin for 'paths' - was designed to handle the movement of individuals from one ‘situation’ to another, through any combination of pathways, up to a defined outcome. It already provides Stockport Council’s social workers and partner agencies with a detailed view of cases at all stages.

Translating that approach to hospital discharge provides a single view of the patient that will improve collaboration and reduce the number of ‘blocked exits.’ It will allow health organisations, social workers and charities working with a patient to access and update information, enabling them to make informed assessments and referral decisions based on a single view of consolidated data.

For example, the ward nurse would be able to select the services a patient may require based on dynamic assessments and build up a care and support plan tailored specifically to that patient. Being rules-based, Semitae could help enforce the messages around entitlement to services, improve consistency around implementation of policy, and reduce the pressure on front line staff when having to say ‘no’.

The tool captures data including next of kin and GP to build up a core profile of the patient: target date for discharge; reason for the stay in hospital and any resulting needs, such as physiotherapy; social interaction via a buddy scheme if they live alone; required home adaptations; and, if they are immobile and live alone, plans for someone to check whether there is food in the house before they leave hospital.

A discharge co-ordination team in a hospital could then see at a glance which stakeholders have accepted their responsibility for each patient and focus efforts on those people who don’t have a ‘green for go’ notification.

Importantly, consent to share this core information with relevant multi-disciplinary teams can be gained whilst in the hospital.

Semitae then monitors planned activities against planned outcomes along the entire ‘pathway’. At any stage teams can log in and check and assess the steps already taken towards outcomes and fine tune their collaboration as necessary.

Each stakeholder in the discharge ecosystem can see information about the patients allocated to them; view assessments of the patient’s needs; the data they required to arrange support services; and the projected discharge date - or changes in it. Paper chasing, missed phone calls, wasted visits and resources not being in the right place would all be dramatically reduced; as would delayed discharges.

In order to get the best outcomes for a patient, care and support teams need to work as one around the needs of the patient – regardless of organisational and technological boundaries. Semitae’s configurable framework is designed to support this and can evolve in conjunction with emerging practices without needing the IT team’s intervention.

If you would like to find out more about IEG4 Semitae for Hospital Discharge please join us at one of our two open events: 28 June 2016 in the North West or 6 July 2016 in London. For more information and how to book please visit

Register For Alerts

Keep informed - Get the latest news about the use of technology, digital & data for the public good in your inbox from UKAuthority.