Discharge Improvement: The challenge isn’t the model, it’s the behaviour

As discussed in my last article, across health and care, we are not short of evidence-based models for improving discharge and flow. 

Frailty models, Home First, Discharge to Assess, virtual wards, transfer of care hubs and neighbourhoods all point in broadly the same direction: support people in the least restrictive setting, avoid unnecessary hospital stays, and focus on recovery and independence. 

The recent NHS England Model Discharge Pathway reinforces these principles discussed in this article. The guidance is clear, practical and rooted in what works, but translating it into day-to-day behaviours remains the challenge. 

At Nottingham University Hospitals NHS Trust, IMPOWER worked alongside frontline teams to put these principles into practice, demonstrating that the real challenge is often not the model itself, but the behaviours and ways of working that bring it to life. See how in our NUH case study.

The challenge is turning that understanding into consistent frontline and leadership behaviours, every day, under pressure. 

Knowing What to Do Isn’t the Same as Doing It 

One of the biggest misconceptions in transformation is that agreement creates change. 

A consultant knows that a person who no longer meets Criteria to Reside would recover better at home. A social worker likely supports the principle of maximising independence before long-term care decisions are made. A ward manager may understand the importance of early escalation. 

Yet despite widespread agreement with these principles, they are not always reflected consistently in day-to-day practice. 

Why? 

Because behaviour is shaped by more than knowledge. It is influenced by the realities of workload, risk, organisational culture, competing priorities and what people see happening around them. It is hard to apply the right behaviours consistently, particularly when workloads are high, risks feel significant and others around us are behaving differently. 

Understanding the Behavioural Barriers 

This is where behavioural science frameworks like COM-B offers a useful lens. 

COM-B proposes that behaviour is driven by three interacting factors: Capability, Opportunity and Motivation. For any behaviour to occur, all three need to be present.  

Applied to discharge improvement, leaders should ask three questions. 

Capability: Do staff have the knowledge, skills and confidence required? 

Do clinicians fully understand the discharge model? Are teams confident in the community offer available? Do staff have the skills to have difficult conversations about risk, recovery and independence with patients and families? 

Opportunity: Does the system make the desired behaviour possible? 

Is the right data available at the right time to make informed decisions? Are alternative services accessible? Are multidisciplinary teams structured around supporting flow? Are meetings, ward rounds and escalation processes reinforcing the desired behaviours? 

Motivation: Do people want to behave differently? 

Do they believe leaders will support them? Do they see positive outcomes when they do the right thing? Do they fear blame if something goes wrong? Do they see others behaving in the same way? 

Many discharge programmes focus heavily on knowledge and process redesign. Far fewer spend time understanding whether behavioural barriers exist across capability, opportunity and motivation. 

Yet unless those barriers are addressed, we risk asking people to behave differently within systems that continue to reward the old behaviour. 

Behaviour Is a Team Sport 

Discharge is perhaps one of the most interdependent activities in healthcare. 

A single patient journey may involve acute clinicians, therapists, nurses, discharge coordinators, social workers, community teams, operational managers and family members. 

Success depends on collective action. This is important because behaviour is strongly influenced by social norms. People look to others to understand what is acceptable and expected. 

If they see colleagues routinely delaying decisions until every uncertainty is removed, that becomes normal too. 

The irony is that entire organisations can agree with the future state while collectively reinforcing the current one. 

Culture changes when different behaviours become visible and accepted across the system. 

Understanding and influencing behaviours 

Next to understanding what is required for a behaviour to occur is understanding what it takes to influence and change one. This is where the MINDSPACE framework comes to play. 

MINDSPACE suggests that behaviour is shaped by factors including Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitments and Ego.  

In practice, this helps explain why simply communicating a new pathway rarely changes behaviour. People are influenced as much by what they observe, experience and perceive as they are by formal instruction. 

Several of these principles are particularly relevant to discharge improvement. 

Norms: We Follow What Others Do 

Every organisation has unwritten rules. 

If the norm is to wait, staff will wait. 

If the norm is to ask, “What would it take for this person to get home today?”, behaviour begins to change. 

Creating new norms is often far more important than writing new policies. 

Defaults: The System Shapes Decisions 

People tend to follow the path of least resistance. 

If the default pathway encourages multiple assessments, excessive handoffs and unnecessary waiting, delays become inevitable. 

If the default becomes “Home First unless there is a clear reason not to”, different behaviours emerge. 

Salience: New Ideas Gain Interest and Momentum 

Familiar ideas often struggle to compete for attention against the latest policy initiative, technology solution or organisational restructure. 

Behavioural science tells us that people are naturally drawn towards what feels visible, urgent and novel. MINDSPACE describes this as Salience.  

But Board rounds are not new. Home First is not new. Discharge to Assess is not new. In many systems, these ideas have existed for years but are not consistently applied. So they don’t make the headlines and struggle to feel exciting to teams “who’ve heard this all before”. 

As leaders, our challenge is not always to invent the next big idea. It is often to make proven behaviours visible enough that people continue to prioritise them. 

The Leadership Challenge: Role Modelling Over Messaging 

Another important behavioural science principle is that we are heavily influenced by who communicates a message, often more so than the message itself. In healthcare, few messengers are more powerful than respected clinicians and operational leaders.  

Staff pay close attention to what leaders do, especially when pressure rises. They notice which metrics receive attention. They notice which decisions are challenged. They notice which behaviours are celebrated. 

If senior leaders talk about Home First but continue to reward risk-averse decision-making, staff will follow the behaviour rather than the message. 

Conversely, when leaders consistently ask: 

• What is stopping this person going home today? 

• What support can we put around them? 

• What risk are we actually managing that can’t be done in the community? 

they reinforce a different way of thinking. 

The most successful discharge improvements are often led less through formal programme management and more through visible, consistent behavioural leadership. 

From Programme Management to Behaviour Management 

Most systems do not need another “new” discharge model. They need greater consistency in applying the ones they already have. 

The challenge for systems to answer is whether enough people have the capability, opportunity and motivation to deliver it consistently, and whether leaders are creating the conditions for those behaviours to flourish. 

The systems making the greatest progress are rarely those with the most detailed plans. More often, they are the ones relentlessly focused on four things: 

• Understanding behavioural barriers. 

• Providing actionable data to support decisions. 

• Creating new norms through visible leadership. 

• Reinforcing the behaviours that underpin success. 

If you want to discuss how to best translate best practice in your team, organisation or system, reach out via [email protected].