Skip to content

Q logo

Meet the team


  • Pete Gordon, Head of Emergency Care Improvement, NHS England & NHS Improvement
  • Lisa Christensen, Emergency Care Improvement Support Team (ECIST) at NHS England & NHS Improvement
  • Tracey Sheridan, Associate Director of Operations, South Warwickshire NHS Foundation Trust
  • Calleja Cristina, Sustainability Manager, SWFT
  • Rachel Briden, Integrated Partnership Manager, Warwickshire County Council

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

Discharge to Assess is an innovative approach which sees health and social care professionals work together to help people return home or to care homes sooner from hospital.

In South Warwickshire, the Covid-19 response has galvanised collaborative working across the system to support Discharge to Assess, re-admission avoidance and new models of out of hospital care.

This has been achieved through partnership between South Warwickshire NHS Foundation Trust (SWFT), Warwickshire County Council (WCC), nursing and residential homes and primary care.

New ways of working have included:

  • Integrated system leadership, with support from Public Health
  • More people enabled to go straight home from hospital with integrated support
  • ‘System approach’ to use of step-down beds
  • Close working with out of hospital services
  • Greater use of technology – virtual meetings between staff and remote support for high risk shielded patients

The main positive impacts have been improved patient care and better use of resources.

What does your project aim to achieve?

The unique circumstances of Covid-19 have accelerated collaborative culture embracing new ways of working for benefit of patients and community. Our aim is to see whether demonstrating the environmental and social benefits of the changes can help sustain this.

We will measure and communicate the impact of changes to hospital discharge using ‘sustainable value’, to analyse health outcomes of patients 65+ discharged to residential/nursing homes together with environmental, social and financial impacts.

By capturing the true range of benefits achieved through Covid-19 adaptations and communicating these creatively with involvement of key stakeholders, we aim to nurture ongoing pride and commitment to service improvement, benefiting the NHS, patients and wider community.

Anchoring positive service changes will sustain improved outcomes for patients being discharged to care homes, reducing inequality for the most vulnerable elderly patients.

We will take learning into recovery planning, as well as spread to other services and other organisations.

How will the project be delivered?

The Centre for Sustainable Healthcare (CSH) will work closely with NHS partners to measure impact on work patterns, travel and resource use, alongside clinical and social outcomes. CSH leads work to mainstream sustainability in healthcare and has extensive expertise in analysing environmental and social impacts of service change at national and international level.

Key people from SWFT including the Associate Director of Operations, Out of Hospital Collaborative and the Sustainability Manager, will work alongside the Integrated Partnership Manager at WCC, primary care and residential/nursing homes to provide data and insight.

The Emergency Care Improvement Support Team (ECIST) at NHS England & NHS Improvement will provide support to communicate the benefits to staff and patients, and share learning from the project widely in the NHS.

Evaluation will include the impact of our integrated team and delivery approach to care homes on length of stay in hospital and readmission rates.

How is your project going to share learning?

1)    The Emergency Care Improvement Support Team at NHS England/Improvement will create and implement a local and national communication plan (infographics, press release, staff info, social media) in order to share the project’s learning widely not only with staff, patients and communities in South Warwickshire but also with Q members and across the healthcare system.

2)    Within Warwickshire we will share our learning across health and social care through the 3 Place Delivery Groups (South Warwickshire, Warwickshire North and Rugby), the Care Expert Advisory Group and with providers through Provider Forums.

We will produce a written report and a template to enable other services to undertake a similar analysis. We will take learning about how to embed service changes using a Sustainable Value model into recovery planning, as well as spread to other services and other organisations.

How you can contribute

  • Contribute creative ideas for communication to different stakeholders.
  • Help to draw connections with other existing priorities - local or national
  • Share with own networks
  • Trial the reporting template in other services

Plan timeline

30 Apr 2021 Partner group formed and briefed; monthly review sessions booked
31 May 2021 Evaluation team set up; evaluation criteria agreed by partner group
31 May 2021 Study design agreed by all partners
30 Jun 2021 Comms team present approved comms plan
30 Jun 2021 Data set agreed with all partners; data collection timetable agreed
30 Sep 2021 Data collected
29 Oct 2021 Report structure agreed
19 Nov 2021 Analysis completed
30 Nov 2021 Reporting template agreed
10 Dec 2021 Report drafted for all partners to input
13 Jan 2022 Report finalised
31 Jan 2022 Comms material set agreed with timing on dissemination
28 Feb 2022 Dissemination plan agreed
28 Feb 2022 Webinar held
31 Mar 2022 Evaluation report completed

Project updates

  • 1 Oct 2021

    The project provides a real opportunity to explore if the evaluation of environmental and social impacts in addition to clinical outcomes and quality of care can help with the spreading of good practice.


    • Our partner group has held six weekly meetings. The group has recently been expanded to include representatives from the data team, home first and patient experience.
    • Study boundaries have been established and metrics defined to measure the environmental impacts.
    • Data collection for environmental impact analysis has started .
    • Metrics defined and method agreed to analyse the social impacts.


    • It was challenging to define and agree the boundaries around the changes of the discharge to assess process which have been implemented during Covid-19. In particular, this centered around the boundary between any changes implemented in pathway 1 of the discharge process and the changes which have been introduced to homecare in general. An internal review which had already been conducted by South Warwickshire NHS Foundation Trust helped with this process. The process of defining the metrics for measuring the environmental impact is now completed and data collection is on the way. It has been a real asset to have the data team and a representative of home first at our most recent partner meeting, so they have a better understanding of the project and the data requirements.
    • Due to ongoing pressures on the NHS it is a bit more difficult to engage with the partners outside the regular meetings.

    Next Steps:
    • As soon as data collection will be completed the environmental impact of discharge to assess will be analysed.
    • We will hold 3 focus group discussions to analyse the impact of the changes to discharge to assess on staff. The focus groups will be with staff working for pathway 1, 2 and 3 of the discharge to assess process and examine the impact of the Covid-19 changes on their working lives and their relationships with patients, patients’ families and carers, other health and social care colleagues and their wellbeing.

    How can the community get involved in your project?

    • If anyone has evaluated staff experience either within a focus group discussion or in other ways, we would love to hear from you.
    • Once we completed the analysis of the social and environmental impacts of discharge to assess it would be great to get your input with comms, e.g. feedback on proposed infographics or messaging/media.


  1. Frances,

    This is a great idea and I do hope that you take it forward. If you need any process visualizations done then please let me know as I'd love to help. Good luck with your idea.


    1. Thank you! That sounds brilliant - we will be in touch if the bid is successful, thanks Tom.

  2. Hello Frances

    I have been meaning to make contact for a while now.  I have submitted a project idea that I think shares many ambitions with yours, albeit mine is focusing on the method of helping people to think through the re-framing in whatever work focus they have, whereas I think yours is on looking at a work focus itself (discharge) and seeing how to apply sustainability thinking to reframe that.  Should we have a chat incase we want to collaborate on both, or even combine?  Best wishes, Claire

  3. Hi. My colleague, Pete Dudgeon, and I are working with the Health Foundation to support conversations and collaboration among Q members during this Q Exchange round. This looks a great project which is clearly building on some successful local collaboration with a clear intention to share your learning more widely. There is a Sustainable Healthcare Special Interest group already within the community - it might be helpful to post your idea there to gather comments and a bit of support?

    One other thought - a written report will be helpful, but are there any other practical things that could help share the learning more widely - a webinar perhaps, a QI poster etc?

    Good luck with your idea - we'll look out for possible collaborators that may help!

    Kind regards


    1. Thanks Emma, really good points. We have shared on the SIG and taken on board your suggestions about a webinar and poster - detailed communications plan is to be developed within the project but definitely Q is an important community to help with developing and sharing our thinking and outputs.

Comments are now closed for this post.