The need

For discharge assessment, planning and onward care to work effectively, it is essential for the different parts of the system to work together to provide truly integrated care for the person requiring it. Discharge to Assess includes acute consultants and nursing staff, acute therapy staff, community therapists, social workers, and domiciliary care organisations and staff. The complexity of need and complexity of the different services and care available leads to confusion not only for people and carers needing care but for those working in the system.

The solution

Our team used the unique insight of a behaviour change specialist alongside strategic communications expertise to create an approach that could get under the skin of the issues at play.

The team’s independence from the system and the issues meant we were able to take an impartial and independent look at the discharge process, meeting with people and teams and allowing them to talk openly about their thoughts on discharge and some of the challenges involved in an open and authentic way without risk of causing offence. The team spent 10 weeks focusing on discovery, gathering insight and synthesising findings to inform recommendations and next steps. This included a review of existing documentation, both local and national, and 121 interviews and larger focus groups and conversations. These conversations included frontline staff across all organisations working on discharge in the system, people and carers, voluntary and community groups, and system leaders and managers.

We aligned discovery feedback and insight with the touchpoints along the discharge pathway. This
allowed us to identify pressure points and understand what barriers and challenges are preventing people moving through each stage of the process. It gave clear insight as to where behaviour change and communications could support improvements.

The insight phase resulted in clear recommendations for communications activity informed by behaviour change which we then took forward to develop a multi-channel communications campaign.


In both phases of the project there were some common challenges. Staff working across the NHS and social care are still dealing with the impact and aftermath of the global pandemic. Staff are overwhelmed and dealing with burnout and are now working in a recovery phase which is just as intense – not to mention periods of industrial action adding to pressures.

Getting the headspace and time of staff, from the most senior to the frontline, to participate in the detailed discovery was a challenge. However, the client was incredibly supportive in understanding the importance of this and enabling it where they could. On the same note, staff did talk of change fatigue
and therefore discussion of any new initiatives or ideas was met with wariness.

Finally, the ability to reach people who had, or were, receiving care, and their carers also proved difficult. This had to be done through services we were working with but it was enabled by the client.

I’m explaining to patients what will happen and I don’t understand it myself. Hospital therapist


Through our extensive engagement and insight gathering across multiple stakeholders – including
clinicians, patients, families and carers and voluntary and community sector (VCS) – we found there was
almost unanimous agreement that people were better out of hospital, recovering at home.

However, it quickly became clear that the challenge arose at the transition points in a person’s journey. Staff told us they felt confident in the care they were giving and the part of the journey they were directly responsible for. As soon as it came to transferring a decision or care to another team or organisation, people felt very differently. There was a lack of understanding of the role of other teams and the pressures or challenges they faced.

Download the full case study to learn how we changed behaviour at scale and developed a communications campaign to support this project.

Get in touch

If you have similar challenges in your area and would be interested in exploring how our behaviour change approach could help, please contact Chloe Watson, Head of Design and Change: