Leading the way in improving flow and discharge across Bradford District and Craven

We are proud of how our place-based partnership has instilled an ethos called Act as One. This sees all partners coming together, acting as one to help us work towards our shared purpose and vision of keeping people ‘happy, healthy at home’. 


As a result, the Bradford District and Craven Health and Care Partnership has consistently met and exceeded discharge and flow targets, often held up as an exemplar regionally and nationally. Cutting edge technology, innovative practices and strong relationships across partners aligned to a bold vision are the reasons given for the sustained and improved performance.

We worked together as partners to respond to the pandemic and manage our collective capacity, given that lack of staff was a major issue for all services. We reviewed our operating model systematically during the summer of 2020, using our data and feedback from our staff teams to optimise flow across acute and community services while continuing with winter planning.

We have been bringing together our workforce using data to provoke conversations between staff groups to facilitate flow, improving outcomes on an ongoing basis and focussing on multi-agency decision making, sharing learning across our two acute hospitals covered by our partnership. 

We introduced new roles to assess for discharge in hospital, moving social workers out of hospital to assess people’s longer-term needs. The trusted assessors for the council-managed enablement service (BEST) and short-term social care beds work closely with the discharge team and  voluntary and community sector (VCS) providers. As a result, we are seeing improved outcomes in terms of capacity and benefits to the person. 

Digital innovation

We have advanced digital infrastructures in place across both Airedale NHS Foundation Trust and Bradford Teaching Hospitals NHS Foundation Trust. At Bradford, bed occupancy levels are monitored through our AI powered command centre. The command centre, the first of its kind in the UK, provides real-time information to help make informed decisions on managing patient care and flow.  At Airedale, our Digital Care Hub delivers remote monitoring technology such as Telemedicine and MyCare24 but also acts as our multi-agency referral hub (MARH) providing joint triage of discharges.

We achieve top quartile performance in the country in lengths of stay in hospital. On a weekly basis, hospital admission is avoided for 20-30 people. Despite the workforce challenges in social care, the independent care sector has, on average, supported 40 people a week out of hospital or to short-term home support. 

Working with our VCS

We had already invested as a system (adult social care and health) in the VCS, with care navigators working alongside the discharge team, home from hospital and through a multi-agency support team (MAST) to reduce demand on adult social care. Further investment was made into MAST to expand the capacity during winter 2020-2021 which particularly made a difference for people with mental health challenges and alcohol dependency.

MAST is one of our flagship partnership projects. The MAST team consists of VCS organisations based across both hospitals (Bradford Royal Infirmary and Airedale Hospital) delivering interventions and health messaging in emergency departments and across some wards to support the health system and provide support around some of the identified ‘pressure points’ in the system. 

The team works across emergency departments and wards as appropriate, identifying patients, at all stages of their admissions from triage to the ward, who would benefit from mental health, older person’s services or alcohol interventions. 

During 2020-2021, MAST has achieved the following

  • Supported 1,912 people in hospital, delivering 2,737 sessions of support 
  • Supported 555 people in the community, delivering 1,643 sessions of support 
  • Helped reduce the percentage of people feeling disconnected and unsupported from 61.7% to 20%
  • Before accessing community support, 47.8% of people expressed they were able to seek support independently. This increased to 72.8% after receiving support.

As a result of the successful implementation of the new models, it was recently confirmed that a further £1.2 million in winter funding is being invested into the VCS Alliance to set up wellbeing hubs in communities at place level.

Our system successes

We continue to see great energy and engagement from teams and plan to continue to scale up the implementation. We have already started to integrate this work into our urgent community response pathways and we’re also building it into our virtual ward place plans. A few examples of our joint successes are:

  • Launching and embedding Right to Reside / criteria to discharge in line with national policy. This has promoted and facilitated timely discharge from the trust along the appropriate pathway. 
  • Goals set around reducing long lengths of stay 
  • Agreed an updated model of working as a multi-agency team, including joint triage and decision making around discharge pathways
  • Developed a dashboard/data set which we continue to work on to provide us with ‘one version of the truth’ for our whole place

The Department for Health and Social Care set improvement targets for length of stay in hospital and transfers out of hospital in December 2021, with targets to be achieved by the end of January. We achieved those targets by the first week in January – the best performance across the North East and Yorkshire.