It can feel like adult social care is seen nationally by the media and others through the lens of ‘discharge’ and ‘flow’. When I was President of ADASS, I remember waking up to the radio one morning to a story where the lack of social care capacity was blamed for acute pressures. I got in touch with the speaker to set the record straight. Since then, the conversation has shifted.
There's a greater understanding that the reasons for discharge delay are multi-faceted with NHS and local authority commissioners, social workers and hospital teams all having a role to play. Partners in Care and Health (PCH) recently ran an online session introducing a model designed to help local authorities embed strength‑based social work, particularly within health‑based settings.
Over this Winter, I attended senior delivery meetings with Ministers and NHS colleagues, which had a clear focus on improving hospital processes to get people home quickly and the NHS and local authorities working together to ensure that no-one is in hospital no longer than they need to be.
The interface between acute trusts and adult social care is an important transition point, albeit only one touchpoint when people who need support encounter adult care services. To ensure the best outcomes for people it’s vital that systems work together effectively to reduce avoidable admissions to hospital and reduce delays getting back home.
The Discharge and Admissions Group is a partnership across DHSC and NHSE working with some of the most challenged systems to support improvement. Site visits are co-led by Lesley Watts, NHS Trust Chief Executive, and a serving Director of Adult Social Services (DASS), to bring practical support and challenge. DASSs Bernie Enright (Manchester), Iain McBeath (Bradford) and Karen Fuller (Oxfordshire) have worked with Lesley to ensure there’s a rounded conversation. They have generously shared best practice and connect teams to others who have successfully tackled similar problems.
There’s significant variation in performance that can reflect differences in the pattern of services or differences in local populations. However, it’s clear that variation also stems from factors that are now well understood and evidenced. These include the quality of relationships and leadership, effective processes, strong intermediate care services and good, joined up support in people’s homes. Local authorities having a critical role in providing step up and step down reablement and taking a strengths-based and recovery focused approach, keeping people in their own homes wherever possible.
PCH have led the BCF support programme and co-produced several High Impact Change Models to support local improvement.
Feedback from across the country on how systems are working hard at the interface to support people to live well at home has highlighted key success factors. Why this is important is we know is that the more time people spend in hospital, the more they are likely to deteriorate, the poorer their experience and the less likely they will be able to return to their own homes.
Here are six themes emerging most strongly from the evidence on what drives meaningful, sustainable progress:
Strong leadership and shared ambition Image from https://freepik.com/One message comes through loud and clear: leadership matters. Trusts and local authorities demonstrating the strongest improvements have leaders who set a clear and consistent vision, one that everyone—from clinicians to operational teams—can rally behind.
Senior leaders aren’t just setting goals; they’re creating the conditions for constructive challenge and long-term change. Regular collaboration across health and social care reinforces this shared purpose and keeps momentum strong.
Integrated, multi-disciplinary workingSuccessful systems are breaking down traditional boundaries. Integrated working across acute, community, and social care settings is becoming the norm rather than the aspiration.
Examples from Oxfordshire and Nottingham show the power of bringing multidisciplinary teams (MDTs) together for daily reviews. Co-located teams are helping build a “one team” culture—shortening communication lines and enabling faster, better-coordinated decision-making.
Operational discipline and clear governanceImprovement doesn’t happen by chance. Trusts with sustained progress are underpinned by strong governance, standardised processes, and rigorous performance oversight.
Operational tools such as “green day” status or RAG ratings are providing clarity, consistency, and a common language for identifying issues early. This discipline ensures teams stay aligned and focused on what matters most.
Data-driven decision-making Image from https://freepik.com/A robust data infrastructure is proving transformative. Organisations that invest in real-time analytics and accessible dashboards can monitor key metrics daily—such as No Criteria to Reside (NCTR), length of stay, and discharge readiness.
This isn’t data for data’s sake; it’s enabling teams to spot trends, act quickly, and continuously refine how they work.
Home first, person centred careThe “home first” ambition is no longer a slogan—it’s shaping pathways and practice. Trusts are recommitting to what’s best for patients: care that supports independence and recovery in familiar surroundings.
Innovations like virtual wards, enhanced recovery pathways, and technology-enabled care are helping make this a reality, reducing hospital stays and improving outcomes.
Tackling challenges and strengthening enablersTeams were honest about the barriers they face. Cultural change, gaps in community capacity, inconsistent practices, funding constraints, and difficulty integrating social care data all continue to challenge progress.
Yet trusts that are succeeding share common enablers: long-term investment, joint funding of critical roles, and flexible models that respond to local needs. These examples show that while the challenges are real, they’re far from insurmountable.
https://socialworkwithadults.blog.gov.uk/2026/03/10/discharge-what-works/
seen at 20:40, 10 March in Social work with adults.