The national demand for increased acute bed capacity highlights a critical need to streamline the patient discharge process. This urgency is highlighted by the NHS England Delivery plan for recovering urgent and emergency care services, which places a significant emphasis on relieving pressures experienced by hospitals. Currently, 19 in 20 beds are occupied, emphasising the strain on existing resources. 

Cambridge and Peterborough Integrated Care System (C&P ICS) is a partnership of health and care organisations, local councils, and Voluntary, Community and Social Enterprise (VCSE) that aims to improve the health and wellbeing for around one million people in the region. C&P ICS commissioned Healthcare Innovation Consortium (HIC) to conduct an initial piece of discovery to understand the inefficiencies associated with delayed transfers of care, ultimately impacting patient care across the system.  

The aim of the project was to gain insight into the current ways of working to facilitate discharge from the acute setting and to make an informed decision on the wider transformation of the service for the transfer of care. 


Efficient healthcare processes require a well-coordinated approach. However, the current landscape faces significant challenges that hinder the effectiveness of patient discharge procedures. 

  • Uniformity – Inconsistent terminology and standardised processes across the System. 
  • Data Sharing – Limitations on the sharing of data between service providers. 
  • Real Time Views – Delay in real time data, impacting discharge decision making.  
  • Education and Training – A lack of knowledge on processes and required information.


Engaging with 35 stakeholders through workshops, interviews, and surveys, including valuable feedback such as “Coordination is pretty good – [what we need] is better information…we rarely get all the information we need” and “[We need] Early identification of care and health needs”, has enabled the mapping of existing discharge planning pathways plus has identified process improvements and address gaps hindering an improved process implementation. 

The feasibility of a new digital solution has been evaluated by HIC, presenting an opportunity to enhance discharge procedures. Valuable insights, comprehensive recommendations, and a strategic roadmap for optimising Discharge Referral Services has been produced to overcome the challenges hindering the effectiveness of patient discharge procedures in the current healthcare environment. 


  • The engagement findings provide a clear indication of a pressing need for service improvement, as well as insights into the priorities of stakeholders 
  • Patient-centric future process flows for discharging planning services designed based on findings. The design addresses the identified needs of stakeholders, aligns with the broader goal of ensuring patient satisfaction and well-coordinated care throughout the discharge planning journey.  
  • Informed Options Appraisal, recommending the Shared Care Record as a potential solution to address identified barriers and challenges, incorporating discovery insights and outlining a roadmap for achieving service improvement. 


  • Identification of user challenges to inform user requirements for service transformation 
  • End-to end visibility of patient pathways mapped to highlight gaps in current services 
  • Digital solution feasibility  
  • A defined roadmap to improve services  
  • Informed decision making for the procurement of new and, enhancements to existing solutions. 

If you would like to speak with the team about how we can help you with Healthcare Discovery, Implementation, and Success, please fill out our Engagement Form and someone from the team will be in touch.