Central Bedfordshire: Hospital Discharge Service - Person Tracker

To provide an equitable hospital discharge experience for residents whilst improving performance associated to delayed transfers, a bespoke Hospital Discharge Service was established in October 2017, with the use of iBCF monies to expand the council’s ‘discharge team’ located at the hospital where the greater number of admissions historically occurred. This example of a local initiative forms part of our managing transfers of care resource.

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The population of Central Bedfordshire is discharged from in the majority, seven feeder hospitals, all of which are placed outside of the geographical boundary of the local authority. As a consequence, when being discharged from hospital, residents were receiving an unequitable and dis-jointed approach to discharge planning, with variable outcomes and flow experienced for people between the various hospitals. Central Bedfordshire was an outlier in its performance relating to delayed transfers with various systems and processes to manage both people and their associated data when delayed in hospital. We were unable to understand or describe the story behind our residents being delayed in hospital and deliver integrated outcomes for people in the wider multi-disciplinary and primary care network.

The plan

To provide an equitable hospital discharge experience for our residents whilst improving performance associated to delayed transfers, a bespoke Hospital Discharge Service was established in October 2017, with the use of iBCF monies to expand the council’s ‘discharge team’ located at the hospital where the greater number of admissions historically occurred. To support the working of the service and to enable an up-stream approach within the co-located discharge teams that the service operates across, a ‘person tracker’ was developed. The ‘person tracker’ has enabled the council to provide a single point of monitoring for its resident’s admission, flow and discharge data.

The tracker was also required to act as an early warning system when people were at risk of becoming delayed alongside support the council to manage the fluctuating levels of surge/demand outside of the traditional periods of ‘seasonal pressures’. Recognising the variance in outcomes experienced by our residents, there was a critical need to enhance the link and relationship with the wider multi agency and primary care network outside of the hospitals.

It was imperative to identify the most appropriate solution to deliver our objective that supported our local context and demographic. A collaborative approach was taken within the council between operational/front line and informatics/business development colleagues, whereby a working group with significant skill mix and experience was formed. The group in turn undertook a plethora of research and analysis of regional and national shared learning, to design an original proof of concept.


To support the implementation and function of the tracker, the bespoke role of a Data & Intelligence Officer was created, to ensure that both the skills and experience associated to hospital discharge from an operational and delayed transfers perspective were matched with those of an advanced information technology user. A further key factor in creating and developing this role was to ensure that the important relationship between customer data and associated delayed transfers across the various acute hospital trusts was strengthened. A historical key challenge had been the variation in reporting of delayed transfers data from multiple hospitals, with data often being published without agreement of the local authority.

The initial plan and proof of concept that implemented the tracker design, was the creation of a spreadsheet that recorded the key elements of real time data relating to admission, flow and discharge, whereby front-line staff, managers and business development colleagues would provide support and challenge to each other. It became apparent at an early stage and as the tracker gained pace and momentum within the service, that various modifications would enhance its operation and support the tracker to become a maturely functioning tool.

This was exampled by the levels of data supplied by trusts, whereby only the dates a person was delayed and the associated category was shared, with the important objective of being able to tell the story of the customer’s admission and discharge, it was imperative that appropriate dialogue and communication with key stakeholders and partners was maintained. This in turn enabled new processes to be designed whereby more robust data was shared with the service to maintain its handle on supporting customers to leave hospital.


The outcomes of our project are reflected by the significant improvement relating to delayed transfers performance, with the council consistently remaining within its agreed BCF trajectory. Between 2016-17 and 2017-18 there was a reduction in delayed days attributable to social care of 16.03 per cent; as the current year is not comparable due to data availability, data for the time span between April and January was reviewed, and as at January 2017 there were 861 social care delays, January 2018 723 social care delays, and by January 2019 477 delayed days. Thus, between January 2017 and 2018 there was a 12.75 per cent reduction, between January 2018-19 a 22.53 per cent reduction, and overall a reduction of 32.4 per cent.

The tracker coupled with the use of existing software packages has supported the design of dashboards which are used at operational and strategic levels, to understand the journey that residents follow when being admitted and discharged from hospital and importantly ensure equability for our residents when leaving hospital. By utilising the skills and experience within the council in a collaborative approach, we have designed and implemented a now mature system to monitor patient flow and recognise the associated cost savings in doing so.

Next steps

We are planning to now take the learning from our initial project to widen the use of our tracker and provide an overview of interplay between acute and community-based services and facilitate enhanced integrated responses to discharge planning through multi-disciplinary working. Having unlocked critical data relating to our customers and associated hospital admissions/discharge will support the design and implementation of targeted admission avoidance and reduction in length of stay strategies alongside the design of innovative and flexible models and pathways that support the whole population of Central Bedfordshire leave hospital safely.

This case study is an example of the High Impact Change Model (Change 2): Monitoring and responding to system demand and capacity.