Transfer of Care Hub development in Morecambe Bay

A new Transfer of Care Hub is set to launch on Monday 5 September 2022 with the aim of ensuring patients in North Lancashire, South Cumbria and Furness are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support. 

The Discharge Team and Discharge Co-ordinators from University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) will form the hub, working together with partners across the system from health, social care, housing and the voluntary sector, to ensure services are linked and integrated care is provided. 

The Transfer of Care Hub will continue to work closely with the Intermediate Care Allocation Team (ICAT) in North Lancashire, and Adult Social Care colleagues in South Cumbria and North Yorkshire. The Hub structure, and pathways, will ensure integrated working is further developed across Morecambe Bay, to support people to be discharged from hospital. 

The Transfer of Care Hub has been put in place as part of the Trust’s new hospital discharge policy that was renewed this year and is in line with the Government’s Hospital Discharge and Community Support Guidance (March 2022) which states:

“Every local health and social care system based around an acute hospital footprint should have a transfer of care hub whereby (physically and / or virtually) all relevant services across sectors (such as health, social care, housing and voluntary sector) are linked together. 
 
“The transfer of care hub should coordinate care for people who require formal care and support after discharge from hospital, and any support for unpaid carers providing care. 
 
“Hubs should be staffed by a small team, dedicated to ensuring people are discharged from hospital on the right pathways, with the right discharge information, and that they get the right onward care and support (if needed). 
 
“Staff based in the transfer of care hub may also be the care givers and rehabilitation professionals for an individual. 
 
“Decisions about what long-term support package is needed should not be taken on the hospital ward.”

Tracy Ashton and Sharon Doyle, Discharge Leads at UHMBT, said: “Through the Transfer of Care Hub we aim to improve patient experience. We will have greater oversight through partnership working and aim to discharge patients more promptly and this will help to reduce risks including hospital-acquired infections including Covid and prolonged length of stay in hospital.

“The Transfer of Care Hub aims to improve patient flow throughout our hospitals and potentially take the pressure off the front door including reducing waiting times in our Emergency Departments.”

In Morecambe Bay, work has been ongoing since summer 2021 to develop a Transfer of Care Hub, with development workstream meetings taking place every fortnight. 

Partners involved in the development of the hub are Cumbria County Council, Cumbria Care, Lancashire County Council, NHS Lancashire and South Cumbria Integrated Care Board (formally Morecambe Bay Clinical Commissioning Group), colleagues from the voluntary sector, Lancaster City Council, South Lakeland District Council, Barrow Borough Council, North West Ambulance Service, Lancashire and South Cumbria NHS Foundation Trust and Midlands and Lancashire Commissioning Support Unit. Local hospices have been instrumental in the hub’s pathway development. 

Dee Houghton, Deputy Chief Operating Officer for Community at UHMBT, said: “Ongoing development work is initially focusing on hospital discharge pathway reviews, developing an e-dashboard and also to review supporting services for discharge such as availability of transport.  
 
“The timeliness of medication being available for patients leaving hospital, transportation and the availability of reablement and adult social care services, are some of the vital services essential for a Transfer of Care Hub to be effective.

“Through a recent engagement opportunity, colleagues from partner organisations have indicated, to support hospital discharges, the core hub team should be formed by UHMBT discharge teams at Furness General Hospital and Royal Lancaster Infirmary, with input from other professionals as required.”

If you would like any further information or may like to be involved in Hub development, please contact Tim McCracken, Interim Project Manager, at tim.mccracken@mbht.nhs.uk