Managing Hospital Discharge Pressure With Commissioners and System Partners in Older People’s Services
Hospital discharge is one of the most visible pressure points in older people’s services. Providers are often asked to admit quickly, manage incomplete information, and stabilise people with complex needs while system partners manage flow. Where this goes wrong, the consequences are immediate: safeguarding concerns, placement instability, and commissioner scrutiny. Two useful internal reference points are the Working With Commissioners, ICBs & System Partners tag and the Social Care Mini-Series — Tendering, Safeguarding & Person-Centred Practice. This article sets out how providers can support discharge safely while protecting service quality.
Why discharge pressure quickly becomes a governance issue
Discharge challenges are rarely about willingness to support. They are about risk transfer. Hospitals need beds; commissioners need flow; providers inherit complexity. Without clear boundaries and governance, discharge pressure can lead to unsafe admissions, staff overload and rapid escalation.
Commissioners look closely at how providers:
- Assess readiness for admission.
- Escalate gaps in information or resources.
- Stabilise people in the first 72 hours.
- Evidence decision-making when accepting or declining referrals.
A provider-led discharge readiness model
Pre-admission risk clarity
Providers supporting discharge should use a structured readiness checklist covering mobility, cognition, behaviour, continence, medication complexity, and escalation pathways. This protects both the person and the service.
The first 72 hours rule
The first three days post-discharge carry the highest risk. Services that manage this well plan enhanced observation, senior oversight and rapid review during this period.
Clear escalation back into the system
Escalation routes should be explicit: who to contact, thresholds for re-referral, and what interim controls are in place while waiting for response.
Operational examples from day-to-day practice
Example 1: Late-day discharge with incomplete information
Context: A person is discharged late afternoon with limited therapy input and unclear moving-and-handling guidance.
Support approach: Provider accepts with conditions and implements enhanced oversight.
Day-to-day delivery: Senior staff complete an immediate manual handling review, restrict unsupported transfers, and allocate experienced staff on the first two shifts. OT input is chased the next morning.
Evidence of effectiveness: No falls or injuries occur; updated guidance is embedded within 48 hours and recorded in governance logs.
Example 2: Discharge of a person with delirium and distress
Context: Hospital discharge follows an acute infection, with fluctuating cognition and distress.
Support approach: Short-term stabilisation plan with clear review points.
Day-to-day delivery: Staff use reassurance routines, consistent staffing and environmental cues. Observations and behaviour notes are reviewed daily by the manager.
Evidence of effectiveness: Distress reduces within days; no safeguarding escalation is required; family confidence improves.
Example 3: Medication complexity post-discharge
Context: Multiple medication changes increase error risk.
Support approach: Medicines reconciliation and enhanced MAR oversight.
Day-to-day delivery: Senior staff verify discharge summaries, liaise with pharmacy and GP, and conduct daily MAR checks for the first week.
Evidence of effectiveness: No missed doses; audit evidence supports safe practice.
Explicit expectations
Commissioner expectation: Providers will support discharge while clearly evidencing risk management, capacity limits and escalation.
Regulator expectation: Admissions are safe, person-centred and supported by competent staffing and oversight.
What commissioners want to see during discharge pressure
Commissioners typically look for evidence of decision-making, not blind compliance. Clear records of acceptance criteria, stabilisation plans and escalation protect both people and providers.