How partnership working in Sefton is creating a person-centred approach to hospital discharge


Urgent care services in Sefton are working with the local voluntary, community, faith, and social enterprise sector to reduce hospital admissions, enable safe, effective discharge and support unpaid carers through a wrap-around, holistic service that puts the patient and their carer at the centre of their support.  

Organisations involved

Cheshire and Merseyside Integrated Care System (ICS), Sefton Council, Sefton Carers Centre, and Sefton Council for Voluntary Service (CVS).

What was the aim/problem?

The aim of the partnership is to provide a holistic approach to care following hospital discharge to ensure that patients stay better for longer and have access to the support they need.

What was the solution?

To achieve this, partners from a range of voluntary, community, faith, and social enterprise (VCFSE) organisations such as Sefton Carers Centre and Sefton CVS have worked together to provide a range of support to people using services, and their carers. 

The Sefton CVS Hospital Discharge Service supports people to settle back at home following discharge from hospital or other similar health settings. It provides free, practical support for up to six weeks to help reduce the likelihood of unnecessary readmissions to hospital. This includes help with shopping, access to Careline or assistive technologies, support to make and keep appointments, regular welfare telephone calls, home visits and feedback to clinicians on the outcome of referrals.

The Sefton CVS Hospital Discharge Service works with Sefton Carers Centre to provide this holistic wrap-around support not only for patients coming home from hospital, but also their unpaid carers. They work closely with the individual and their carer to identify their needs and develop a bespoke support plan. This approach puts the carer and patient in the centre of their support and promotes choices to give them the right support, at the right time, to keep people independent and at home.

Another output from the partnership is the High Intensity Use of Service Team which identifies what is driving repeat attendances to A&E and helps guide individuals to more suitable support. That can include help from the Sefton Crisis Cafés which deliver person centred, non-clinical, out of hours support for those at risk of suicidal thoughts, homelessness, people escaping domestic violence and people who are struggling with their mental health. Additional resource comes via Sefton Carers Centre’s expanded NHS partnership which enables people to access one-off personal health budgets to help with timely and effective hospital discharge – such as paying for home items like microwave, bedding or clothes.

“Unpaid carers are crucial in maintaining the care system, equating to 4 million paid carers.” Vicky Keeley Chief Executive Officer, Sefton Carers.

What were the challenges?

Sefton has a diverse population with some of the most affluent and deprived areas in the country. This poses challenges for the commissioning and delivery of services with high occupancy rates in the three local hospitals, and Southport hospital rarely below 98% occupancy.

Building partnerships takes time and can be challenging; barriers to working together included: 

  • Overcoming organisational boundaries to encourage meaningful partnerships.
  • Lack of understanding from other sectors about what the VCSFE sector can offer.
  • The focus on clinical services rather than wider determinants of health.
  • Habitual ways of working and culture.
  • Lack of involvement of carers in decision-making about those they care for.

What were the results?

The work has strengthened links with wider system partners and enabled knowledge exchange across organisational boundaries. The services the partnership provides are low cost and high impact and would not be able to be delivered by the NHS alone. The partnership has also helped identify and tackle further support needs, such as Sefton Carer’s Centre’s work with personal assistants and personal health budgets. 

Working across system partners has led to a holistic family-centred approach to health and care in Sefton which has improved the experience of those drawing on services and their carers. The partnership has:

  • Supported over 850 people being discharged from hospital or similar health settings.
  • Provided a same day response to every referral received during operational hours.
  • Kept the readmission rate for people referred to the Sefton CVS Hospital Discharge Service below 5%.
  • Supported applications for benefits and grants totalling over £250,000 between May 2022 and March 2023. For example, the team have helped people access emergency heating vouchers and benefits to pay for food, clothing, and transport to medical appointments.
  • Enabled the Hospital Discharge Service support workers to attend home visits, raise safeguarding concerns and secure clinical support, which has prevented crisis situations and loss of life.

“This is all because of you, I honestly can’t say how great this is. I never thought I would be in a warm flat with new clothes and a car at the start of this year. I can’t thank you enough.” Brian, Hospital Discharge Service user.

“Thank you for your help, kindness and patience and of course the laughs, we have looked forward to every call and visit you have made to us.” Hospital Discharge Service user.

The Sefton Crisis Café saved my life – resident’s story 

What were the learning points?

  • Mutual trust and respect between system partners is crucial to create an environment where all partners can provide challenge to build services that work for people and communities. Working with a diverse range of local voluntary sector partners provides insights which help partners to co-design care and support plans that meet local needs. This shared insight and contribution helps form a more effective system response to tackling immediate problems as well as creating long term solutions. 
  • Taking a holistic family approach to health and care is important to ensure that care provided by unpaid carers can be sustained. Unpaid carers are crucial in maintaining the health and care system, which research from Carers UK and the University of Sheffield estimate to equate to £162 billion in economic value England and Wales (Petrillo, 2021). Unpaid carers should be empowered and accepted in their knowledge of the cared for and their condition. They need practical help, financial support, assistive technology, legal and workplace rights in place to enable them to be a carer.
  • It is critical to look beyond the medical model of health when delivering effective person-centred care and discharge support. The wider determinants of health such as housing, environment and employment should be considered when supporting patients and carers to remain well and at home. Providing practical support will reduce hospital admissions and ensure that patients get the help they need from the right service.

Want to know more?

Hospital Discharge (

There are a range of tools and resources available on the Future NHS Platform – Working in Partnership with the Voluntary Community and Social Enterprise Sector, including role descriptions, business cases, board papers, formal agreements between VCSE Alliances and ICBs and case studies.

For more information: