Overview
The ‘Guiding You Home’ programme was established in 2025 as a collaboration between South Tyneside Council, Sunderland City Council, South Tyneside and Sunderland NHS Foundation Trust; and North East and North Cumbria ICB.
The programme sees multi-agency teams working collaboratively with ward staff, care homes and home-based care services to find more effective ways of working – with the focus on helping patients get discharged faster, or stay out of hospital altogether, with more help provided at home.
Action
A detailed diagnostic was carried out to identify areas of opportunity:
- Reducing admissions through the strengthening of preventative approaches
- The efficiency benefit of reducing hospital discharge delays
- Reducing length of stay in IMC beds
- Shifting the focus to more capacity for home-based support
A central focus was placed on system leadership and fostering a culture of shared ownership over both risks and benefits. By distributing responsibility and reward across partners, all organisations were encouraged to contribute actively and remain invested in the success of the overall system rather than just their individual parts. Partnership working between two local authorities ensured a joined-up approach to tackling challenges across different localities, enabling more cohesive planning and delivery of services to meet the diverse needs of the population.
Efforts were made to establish a strong grip on data[SQ1.1], allowing identification of pressure points and emerging issues within the system. This evidence-based approach enabled the partners to respond proactively, ensuring that interventions were targeted where they were most needed and that resources could be deployed efficiently.
A deliberate focus was placed on operational management, underpinned by sharing data and ensuring that the flow of benefits was felt throughout the whole system, rather than concentrating on resolving a single issue in isolation. This holistic view promoted wider improvements and prevented unintended consequences elsewhere.
Implementation was phased, with an emphasis on building confidence through achieving some early, quick successes. These initial wins demonstrated the value of the new approach, helped to secure ongoing buy-in from stakeholders, and laid the groundwork for sustained, longer-term action.
Changes included:
An emphasis on discharge culture, with standard prompts introduced to focus on how to get each person home
- The introduction of focused MDT sessions
- Staff-led improvement cycles to strengthen systems
- Developing a new digital capacity dashboard to manage referrals for reablement
- Integrated social work resources to facilitate Care Act assessments.
Outcomes
This has led to:
- 8% decrease in Pathway 3 starts
- 40% decrease in use of longer term residential care
- Shorter length of stay in intermediate care bedded provision
- Fewer hours of homecare support required
Peers to Contact
Zoe Campbell: [email protected]