Digital Implementation, News, Systems, Thought Leadership April 16, 2025

Data solutions to solve the South West’s patient discharge crisis

By Professor Christos Vasilakis and Dr Zehra Onen Dumlu

Professor Christos Vasilakis, Founding Director of the Centre for Healthcare Innovation and Improvement – CHI²) and Dr. Zehra Onen Dumlu from the University of Bath discuss the IPACS project – a collaborative, data-driven approach to improving patient flow.

Delayed discharges, often known as ‘bed blocking’, is a serious operational challenge for NHS managers across the country. According to NHS England data, in February 2024 there were between 13,200 and 14,200 patients remaining in hospital each day who did not meet the criteria to stay. This accounts for more than one in eight general and acute beds in England.

While patients are deemed medically fit for discharge, they remain in hospital due to complexities in arranging necessary social care or community nursing support for a safe transition. The knock-on effects are significant, placing immense strain on acute bed capacity and negatively impacting patient flow and their experience.

The IPACS project: A collaborative, data-driven approach

To address the issue, the Improving Patient Flow between Acute, Community, and Social Care (IPACS) project was launched in 2020. This significant three-year initiative received funding from Health Data Research UK (HDRUK), an independent charity focused on using health data research to address major healthcare challenges.

IPACS brought together a diverse team, combining academic expertise with frontline NHS operational knowledge. Collaborators included the University of Bath, the University of Exeter Medical School, and significantly, the Bristol, North Somerset, and South Gloucestershire (BNSSG) Integrated Care Board (ICB).

The goal of the project was to develop an open-source computer simulation model capable of analysing the complex dynamics of patient flow. This tool would offer a potential blueprint for healthcare organisations nationwide grappling with delayed discharge pressures.

Central to the project was the application of Operational Research (OR) techniques – using advanced analytical models to dissect and solve complex systemic problems. Several team members brought extensive OR experience, with affiliations to The Operational Research Society, demonstrating the project’s robust methodological foundation aimed at enhancing healthcare efficiency.

A multidisciplinary, team-driving innovation

The success of IPACS hinged on its multidisciplinary collaboration. BNSSG ICB’s Head of Modelling and Analytics, Dr Richard Wood, and University of Bath Research Fellow Dr Paul Forte provided essential insights into real-world healthcare operations and ensured the project outputs were relevant and accessible to NHS decision-makers.

Academic leadership came from Professor Christos Vasilakis (founding director of the Centre for Healthcare Innovation and Improvement – CHI²) and Dr Zehra Onen Dumlu at the University of Bath, working alongside Professor Martin Pitt and Dr Alison Harper from the University of Exeter Medical School. This combined team undertook the intricate task of designing, developing, and validating the simulation framework.

Focusing on the critical ‘Discharge to Assess’ service

A key focus for the IPACS project was the transition of patients from acute settings into community care, specifically via the ‘Discharge to Assess’ (D2A) service. Optimising this service is key to improving hospital throughput. The project modelled the three core D2A pathways:

Pathway 1 (P1): Enabling patients to return home with domiciliary support.
Pathway 2 (P2): Providing bed-based rehabilitation for those needing more intensive recovery support post-discharge.
Pathway 3 (P3): Catering for complex care assessments, frequently leading to long-term care placements.

The IPACS model aimed to help optimise capacity planning and resource allocation across these vital pathways.

The BNSSG region: A relevant testing ground

The Bristol, North Somerset, and South Gloucestershire (BNSSG) region, serving approximately one million people, served as a practical case study. Its demographic mix and blend of urban and rural environments reflect challenges common across the NHS. The region’s D2A pathways were experiencing significant pressure, with high occupancy and discharge delays, providing a rich, real-world dataset and demonstrating the urgent need for the solutions IPACS explored.

Operational Research and simulation modelling in practice

Professor Vasilakis and Dr Wood pinpointed the core management challenge: the complex interdependencies between acute, community, and social care services. Bottlenecks in community and social care inevitably impact upstream services, contributing to emergency department pressures and ambulance handover delays.

The IPACS team used real-time data on patient occupancy and discharge delays to build their model. This allowed them to establish baseline performance and, critically, to run “what if” scenarios, varying parameters like length of stay and arrival rates to understand potential impacts of service changes.

Computer simulation modelling, a cornerstone of OR, was central to this. The model allowed the team to:

Simulate patient journeys through the D2A pathways in detail.
Test potential interventions virtually to assess their likely impact on flow and delays.
Analyse how best to allocate resources to mitigate discharge delays.
Account for time-varying demand patterns.

Built using the open-source ‘R’ programming language, the model prioritised accessibility and transparency.

Demonstrating real-world impact and future potential

The IPACS model provided valuable quantitative insights. Outputs clearly demonstrated the potential benefits of achieving target pathway splits and reducing lengths of stay within the D2A service. Significantly, estimates generated by the model were used to support a £13 million business case for enhancing the local D2A system – highlighting the project’s tangible value in informing strategic investment decisions.

The team acknowledged the model does have some limitations. It doesn’t yet capture every element of discharge, such as specific social care inputs, palliative care routes, or detailed post-D2A placement dynamics. Data completeness also needs some ongoing attention. Future work could involve expanding the model’s scope to incorporate social care elements more deeply, analyse the impact of acute capacity constraints, optimise home-based care models, and potentially develop faster analytical tools.

The ongoing challenge and strategic steps forward

Tackling delayed discharge requires effective strategies, and the IPACS project highlights the value of OR. Using OR methods such as simulation modelling allows NHS managers to better understand complex discharge pathways, evaluate potential solutions before implementation, and make more informed, evidence-based decisions about resource allocation to improve patient flow and reduce delays.

*Dr Zehra Onen Dumlu, Assistant Professor, University of Bath*

*Professor Christos Vasilakis, Founding Director, Centre for Healthcare Innovation and Improvement – CHI²*

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Embedding social prescribing in secondary care: A toolkit from Barts Health

By Gabriel Blaazer

Barts Health NHS Trust and its partner organisation, Transformation Partners in Health and Care, have released a toolkit detailing their pioneering work embedding social prescribing in secondary care and specialist acute pathways. The toolkit aims to help providers address unmet social needs, improve patient outcomes and reduce demand on acute services, shaping a holistic, prevention-focused model for the future NHS.

Social prescribing attempts to address the social determinants of health. These are the non-medical factors influencing 84 per cent of a person’s total health, with clinical care impacting the remainder. Social determinants of heath include income security and employment, education, housing and food insecurity, or social isolation.

Introduced in England in 2018, it typically involves signposting or referrals to appropriate services, but can also include emotional and mental health support for people experiencing social isolation or low-level mental health issues. Social prescribing is a holistic, person-centred and preventative approach and as such, is a key enabler of the government’s efforts to shift more care into the community and bolster prevention initiatives.

Emerging evidence suggests that social prescribing is an effective, yet low-cost, preventative intervention. However, its implementation has been more frequent in primary and community care, compared to secondary care. In 2023, Barts Health NHS Trust (Barts Health), one of Europe’s largest acute healthcare providers, started implementing social prescribing across multiple pathways, using different integration models to support a whole system approach to prevention and personalised care.

These services, delivered by social prescribers in collaboration with clinical and wider multi-disciplinary teams, support residents with their social needs while aiming to reduce demand on high-pressure services, including cardiovascular (CVD), renal, emergency care, and children and young people’s (CYP) services.

Encouraged by positive outcome data, the Trust and its partner organisation, Transformation Partners in Health and Care (TPHC), have developed a toolkit to help secondary care services embed social prescribing, public health and other community-led prevention initiatives within their specialties and pathways. The toolkit serves as a practical guide and checklist for secondary care providers looking to implement social prescribing and explore integrated, whole-system approaches to prevention.

Addressing unmet needs

While NHS England has established a standard model for embedding social prescribing, this has primarily focused on integration within primary care. In 2023, Barts Hospital’s Endovascular Team, led by Vascular Surgeon Dr Tara Mastracci, identified a high prevalence of unmet social need among patients in the hospital’s cardiovascular pathway – a well-evidenced correlation. Given that CVD disproportionately affects socially deprived populations, Dr Mastracci theorised that integrating social prescribing could benefit those at highest risk, simultaneously alleviating pressure on the pathway and improving patient outcomes.

A key data point supporting the use of social prescribing in secondary care was the gender split between typical users of social prescribing services and those presenting with acute cardiovascular issues. While 84 per cent of patients within cardiovascular pathways were men, 60 per cent of social prescribing users were women. Research has shown that women consult primary care services 32 per cent more frequently than men, suggesting that secondary care could play a central role in engaging men, who might otherwise remain underserved by traditional social prescribing models.

“Overall, we have found that we encounter a different group of patients compared with those who access social prescribing in primary care.”

Dr Tara Mastracci, Endovascular Lead for Complex Aortic Surgery, Barts Health

This reinforced Dr Mastracci’s belief in the merit of social prescribing within secondary care – clearly, more effort was needed to engage men, particularly for CVD patients who could benefit from greater social support.

Building a collaborative approach

Several specialties within the Trust had also identified unmet social needs as a key driver of service demand, and had begun implementing social prescribing programmes within their pathways. However, these initiatives were siloed, staff-led and reliant on temporary funding or fixed grants. To enhance collaboration and sustainability, Dr Mastracci established a multidisciplinary network of staff across primary and secondary care to drive a more integrated and formalised approach.

Finding limited guidance on implementing social prescribing within secondary care, Dr Mastracci’s CVD team set out to develop a replicable model for implementing it as part of secondary care pathways. Keen to apply the same rigorous standards as with a medical intervention, the team partnered with health economists at the University of East London. They incorporated EQ-5D instruments and QALY (quality-adjusted life years) metrics to evaluate the potential impact of social prescribing on both patients and the wider health and care system.

Recognising the need for greater institutional knowledge and community expertise, the team also partnered with the Bromley by Bow Centre (now Bromley by Bow Health), a leading VCSFE (Voluntary, Community, Social, and Faith Enterprise) community health organisation. This collaboration led to the embedding of a social prescriber within the hospital’s heart attack pathway, screening patients entering the pathway for financial or other social needs.

Implementation and outcomes

Once identified, social prescribers provided patients with six to eight support sessions, connecting them to local services and community groups tailored to their specific social needs. Beyond financial deprivation, patients received support for needs including housing, talking therapies, and healthy lifestyle support such as smoking and alcohol cessation, or physical activity and weight management – all of which play key roles in determining a person’s risk of developing CVD-related conditions.

The social prescribers were drawn from diverse backgrounds and communities, to work in collaboration with clinicians and consultants from secondary care, patient advocate groups, VSCFE organisations and others. This multidisciplinary approach facilitated a holistic and patient-centred approach. The experiences and lessons from creating the CVD social prescribing pathway were later used to inform other specialties as they implemented similar services within their pathways.

“We believe strongly in the importance of ‘place’ and thus many of our social prescribers meet patients in the community where they live to engage and provide support.”

Dr Tara Mastracci, Endovascular Lead for Complex Aortic Surgery, Barts Health

Dr Mastracci acknowledges that it will take years to fully assess the impact of Barts Health’s social prescribing programmes. “We know these target groups are admitted at higher rates than their peers,” Dr Mastracci told ICJ, “but it will take years to evaluate the long-term effects.”

Despite this, early results have been promising, notably within children and young people’s (CYP) diabetes services. Led by Dr Myuri Moorthy, Diabetes Consultant and Clinical Lead for Young Adult Diabetes (YAD) at Barts Health, clinicians in the pathway had noticed a concerning increase in non-adherence to self-management protocols, often linked to concurrent financial and psychosocial issues. The service also saw high numbers of patients not attending appointments (DNAs), largely due to distress, burnout, and the intense mental health toll associated with diabetes.

Poor diabetes self-management is well known to increase the likelihood of complications. This prompted the diabetes team to adopt a co-designed and personalised model, including a multi-disciplinary team of social prescribers, youth workers and a psychologist. The aim of the YAD Social Prescribing Service was to improve patient engagement, reduce DNAs and maximise the impact of each clinical appointment.

Together with service users, the team co-developed a series of interventions, including monthly peer support meetings, a WhatsApp group and a ‘walk and talk’ group, securing funding from NHSE for two and a half years. During this time, the team successfully:

Reduced the DNA rate across the Trust from 39 per cent to 12.5 per cent
Cut diabetes-related hospital admissions of CYP by 36 per cent across all Barts sites
Generated financial savings of an estimated £62,500 per year across the Trust

More outcomes from the prevention initiatives across Barts Health, including economic and demand savings, stronger integrated community networks and improved outcomes and patient experience, can be found on pages 26-30 of the toolkit.

Gaining leadership buy-in

As with many prevention-based interventions, the impact of social prescribing on health and care systems can take years to fully assess. In its paper on integrated neighbourhood teams (within which social prescribers typically sit), The National Association of Primary Care suggests that “savings will be non-cash releasing, but this is not as issue as what is required is capacity and health improvement.” However, this long-term approach does not easily align with NHS funding cycles, which typically require demonstrable return on investment within 12 months.

Currently, all of Barts Health’s social prescribing pathways are funded individually, on an ad hoc basis. The CVD project, for example, was initially funded by NHSE, but is now supported by Barts Charity. To move towards trust-wide funding, TPHC’s Secondary Care Project Manager, Mollie McCormick, emphasises the need to develop:

Robust databases and coding frameworks to accurately track interventions and outcomes over time
Qualitative data collection from patients benefiting from social prescribing, with an emphasis on reduced need for healthcare services and thus cost savings

Bridging the gap between identifying social needs that drive demand and demonstrating short-term cost savings remains a challenge. However, securing the backing and support of senior clinical leadership is critical in building the case for long-term investment.

For social prescribing initiatives to gain trust-wide funding in future, structural changes are needed to prioritise long-term prevention and strengthen outcomes-based commissioning. Different approaches could involve integrated care systems incentivising prevention by:

Setting realistic and appropriate prevention targets for NHS trusts to influence commissioning decisions towards the implementation of personalised care and prevention initiatives
Introducing penalties for avoidable readmissions

These targets could be assessed by monitoring readmission rates for specific condition cohorts or high-demand service areas, ensuring a measurable focus on prevention.

The toolkit: Embedding and Connecting Prevention in Specialist Pathways

Barts Health and TPHC have now published their toolkit, Embedding and Connecting Prevention in Specialist Pathways. Along with background information on the benefits of social prescribing and community-led prevention, the toolkit addresses some of the key systemic barriers that Barts Health encountered while implementing initiatives across various pathways and specialties.

Using case studies and the first-hand insights from patients, social prescribers and clinicians, the toolkit offers practical guidance for those looking to implement community-led prevention approaches, such as social prescribing, in secondary care. It also provides an overview of key Barts Health prevention networks and identifies the leaders driving this work across the Trust. The toolkit offers a valuable resource for anyone working in an acute setting wanting to embed social prescribing into their services or to prioritise the prevention of ill health in NHS Trusts across London and nationally.

Social prescribing: A key enabler of NHS prevention goals

Emerging evidence strongly supports social prescribing as a cost-effective intervention for tackling the wider determinants of health and addressing the often-overlapping health inequalities that contribute to high demand for NHS services.

Further, as the government seeks to move more care from hospitals to communities as part of its ‘three shifts’, initiatives like social prescribing will be increasingly vital. By reducing pressure on secondary care services and helping local systems meet their financial and operational goals, social prescribing plays a crucial role in shaping the future of preventative, person-centred and sustainable healthcare.

Special thanks to Dr Tara Mastracci, Endovascular Lead for Complex Aortic Surgery at Barts Health, and Mollie McCormick, Secondary Care Project Manager at Transformation Partners in Health and Care, for their time and input in developing this article.

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UK digital health company launches Prevention Innovation Fund to support ICSs

By Integrated Care Journal

Holly Health has announced a £320,000 fund, offering systems access to psychology-based digital health services, enabling system leaders to move forward with prevention initiatives.

Long-term conditions (LTCs), mental health challenges, and multimorbidity rates are rising, with lifestyle risk factors the biggest cause. This is impacting system costs (£18.4 billion, or over three quarters of NHS expenditure, is spent on long-term care per year) and workplace sickness (38 per cent of people of working age on long-term sickness, report having 5 or more LTCs). The vast majority of people living with these challenges currently get no tailored support for lifestyle health improvement.

Holly Health has today announced a £320,000 Prevention Innovation Fund, offering up to four integrated care systems (ICSs) (or equivalents in Scotland and Wales) up to £80,000 credit each towards deploying a proven, psychology-based digital health coaching service, to increase self-management support across their region.

The goal of the fund is to help NHS system leaders to move forward with large scale prevention initiatives efficiently, supporting progress towards the three new UK healthcare strategy ‘shifts’, from treatment to prevention, hospital to community and analogue to digital.

Holly Health is a fully digital, yet personalised, health coaching service which supports patients to develop sustainable health habits across mental and physical health and most lifestyle risk factors.

Backed by the NHS Innovation accelerator, and with more than 200 GP practices partnerships around the UK, Holly Health outcomes show significant average health improvements across areas like exercise, mental wellbeing, weight and blood pressure. Additionally, GP appointments show consistent reductions after using Holly Health, especially in more frequent service users.

Steve Woodford, NHS Non-Executive Director at NHS England, said: “The NHS has an opportunity to shift towards a proactive, preventive and personalised care system, with the help of technology. Services like Holly Health can help to drive these changes affordably and efficiently. This is a great opportunity for ICB teams, enabling scalable self-management support for people living with or at risk of long-term conditions.”

There are two main ways in which ICSs will be able to launch Holly Health at scale. One is via traditional routes, deploying Holly Health via primary care and public health services. The second, a route fit for the future NHS, is to launch Holly Health to members of the public, via the NHS App, made possible by a brand-new collaboration between Holly Health and Patients Know Best, also announced today.

Patients Know Best (PKB) is the UK’s leading personal health record platform, enabling patients to access and contribute to their health records using the PKB website and via the NHS App. The new Holly Health and PKB integration allows the Holly Health digital health coaching service, and PKB records to ‘speak’ to each other, so that members of the public can transfer blood pressure readings and lifestyle health data into their personal records. ICS teams will also have the new opportunity to reveal access to Holly Health coaching, via PKB and the NHS app, supporting the government’s vision for a single place for people to manage their health.

Grace Gimson, chief executive at Holly Health, said: “We’re extremely excited to make this double announcement: the launch of our Prevention Innovation Fund, and go-live of our partnership with PKB. Both have the potential to drive huge systemic changes in UK healthcare, driving prevention and personalised patient care forward, at population scale.”

Mohammad Al-Ubaydli, chief executive at PKB, said: “Holly Health’s pioneering approach to preventative care, perfectly complements PKB’s mission of empowering patients with their health data. Together, we’re creating a seamless experience where patients can proactively manage their wellbeing and maintain a complete, holistic view of their health, all in one place to share with whoever they need to.”

ICSs, and their equivalents in Scotland and Wales, wishing to find out more about the Prevention Innovation Fund, and to apply, should contact hello@hollyhealth.io.

Catherine Davies, Director of Digital Healthcare Council, commented: “Holly Health’s new Innovation Fund is a great opportunity for NHS systems to deploy evidence-based solutions at scale. Their digital health coaching helps accelerate the Government’s three shifts, particularly from treatment to prevention, delivering measurable outcomes for the NHS while empowering patients to take control of their health.”

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