Transfers of Care

Following a national review of the Discharge Transfers and Transitions of Care National PSC cluster it was agreed the cluster would be stood down. Please see our report for information of the work to date. The cluster members across the AHSN will remain in contact as a community of practice.  

Why this priority?

Patient journeys are full of transitions. Arguably, the most obvious transition is what we often call ‘discharge’ where the patient leaves hospital and returns to a community setting. Transitions are actually much more common than just this. During a hospital admission patients will transition between different clinical teams, wards and departments each requiring a form of handover. As patients age they also transition between care providers, which can raise problems for the continuity of care.

We are working at the forefront of identifying and sharing lessons that promote safer care transitions. We are working with health and social care partners to find evidence of what works to improve safer transfers of care and to spread this learning across the region. We are also working closely with NHS England on a national programme of work to develop similar learning across the entire NHS.

The East Midlands PSC is leading a discharge cluster in collaboration with eight other PSCs, NHS England, NICE and other agencies to share best practice. Our case studies and more information can be found on the NHS England website.pdf Our latest East Midlands PSC discharge case study is available here

We are grateful to the organisations that have worked with us across the region to compile these case studies and encourage others to share examples of their work in this area.

pdfDischarge Case Studies booklet.

How big is the problem?

  • Between October 2012 and 2013, the NHS National Reporting and Learning System identified over 10,000 patient safety incidents resulting from the discharge of patients from acute care settings
  • For older patients in particular, 66% of medication errors are associated with transfers of care
  • 749 reports were from the East Midlands. Failures of communication at handover accounted for 33%

Our goal?

Develop a best practice online resource for all organisations concerned with discharge from secondary care settings.

How will we achieve it?

Work with other PSCs through the “Discharge, Transfers and Transitions of Care Cluster” to draw together existing best practice resources, such as the evidence base, case studies and a network of individuals and/or organisations with particular expertise in discharge practice. Identify pertinent technological solutions and practice from other industries. The resource will include case studies, tools, evidence and networking opportunities.

How will we know if we’re making an impact?

PSCs within the cluster are aware of and have access to the shared online resource.

Discharge, Transfers and Transitions of Care Cluster Report

A copy of the final discharge, transfer and transition of care cluster report is available here.

Further recourses

EMAHSN PSC funded the development of a communication framework (SBARD) within Derbyshire Community Trust. SBARD stands for:

Situation: Explain who is calling and why? Be clear about the situation.

Background: How has this come about? What’s the history?

Assessment: What are the problems that you and the person you’re calling identify together?

Recommendation: What do both you and the person you’re calling feel would help?

Decision: What has been agreed, and who will do what?

For more information please contact Cheryl Crocker - This email address is being protected from spambots. You need JavaScript enabled to view it.

pdfSBARD Postcard - Carers and Family

pdfSBARD Carers Handbook

pdfSBARD Report

docxSBARD Report (Police & NHS)

pdfSBARD Police & NHS Communication Tool

Discharge and transfers East Midlands infographic

pdfEast Midlands discharge and transfers of care infographic 2016


We produced a longer evidence review about transfers of care and discharge, visit our SPARKLER page for more information.

SAFER guides

The SAFER guide for local health and social care communities; Transforming urgent and emergency care services in England - Safer, faster, better: good practice in delivering urgent and emergency care produced by NHS England.

pdfSAFER - Patient Flow Bundle
pdfSAFER Guide May 2016