Safe discharge and transfer

Safe discharge and transfer home
Safe discharge and transfer reference group


​Safe discharge and transfer


The patients and carers we consulted as part of the mobilisation of the PSC told us that for too many patients, discharged from hospital did not feel safe for them. They felt poorly informed about what was happening, they did not feel that communication between sending and receiving service providers was adequate and arrangements for being safe at home were haphazard.  We also know that safety incidents, including medication errors and relapse, happen after discharge often resulting in a readmission.

Quarterly update – June 2017

KSS QPSC is developing a new whole system approach to the challenge of ensuring safe discharge and transfer of patients – an approach that it hopes will lead to change in settings across the region.
With an ageing population, a higher prevalence of long term conditions and an associated increase in avoidable admissions, the entire workforce across the local health economy is struggling to meet the increasing demand.
There are a number of reasons for these problems, including a lack of capacity and time to review and address inefficient systems, leading to multiple and increasing pressures on the health and social care system.
These pressures are having a marked impact on patient flow, and improvement in this is now one of the highest priorities for the national and local health economy.

One area that has long been identified as a major cause of poor patient experience and outcomes is poorly managed transfers of care and discharge of elderly patients. KSS PSC is leading the development of a new whole systems improvement programme for a cohort of vulnerable patients across Surrey Heartlands.
The project aims to reduce the impact of this negative domino effect, developing a range of tools that can be used to improve the patient and carer experience of discharge from and transfer between services.

How the project will operate:

The project will take a whole systems approach and will include key stakeholders from across Surrey Heartlands, including health and social Care providers, ambulance trusts, voluntary sector, charities, local councils and patient and carer representatives.
At its first meeting at the end of March, the project team will hear from patients about their experience of being discharged and transferred within the Surrey Heartlands health and social care system.
The team will then map the patient journey and, as a collaborative, identify issues and discuss and determine potential solutions. They will then form smaller relevant project groups to return to their care setting and develop tests of change for their ideas. The group will meet quarterly to share success and challenges, and review overall progress against programme aims for the patients and the system. 

Why Surrey Heartlands first

Operating across the Surrey Heartlands, the project will link closely with the work of the evolving Surrey Heartlands Academy, which will be an enabling inter speciality network - supporting innovation and transformation.

This area was chosen as, compared to national distribution, it has a much larger population aged 40 – 65 and 75+.

In addition, over the next 10 years the number of people aged 85+ living in the Heartlands area will go up by 39% and more than half (55.8%) of the population will be aged 65+.

Progress to date

October 2016: We have collated a wide range of evidence, literature and demonstrate to support the rationale (this can be found here )
December 21016: We reviewed outcome and prevalence data to support the rationale behind first cohort decisions
February 2017: We have had the first Core Reference Group with representatives from across the local health and social care system including patient leaders to agree on the priorities
March 2017: We have held our first Breakthrough Series event with over 70 delegates in attendance from the Surrey Heartlands locality to explore issues and solutions using Value Stream Mapping
May 2017: Continued support from Healthwatch Surrey and the Patient Leaders confirmed and plans for co-working discussed
May 2017: Workstreams established to be agreed; Primary Care, Communication, Integration and Safe Meds on Discharge

What’s coming up

12 June 2017: Core Reference Group (click here for more info )
June / July 2017: the workstreams will be established and first meetings to take place
August 2017: Project Initiation Documents developed and work on the workstreams to commence
August 2017: SDT website to be updated and workstream plans and project teams updated
Sept 2017: 2nd Breakthrough event to be held and presentations on developments, plans and progress to be provided by the workstreams.