Integrated Discharge Hub: Patient experience report

Healthwatch Milton Keynes was commissioned by the Milton Keynes Health and Care Partnership, with support from the Bedfordshire, Luton and Milton Keynes Integrated Care Board (BLMK ICB), to undertake an independent evaluation of patient experience of discharge through the Integrated Discharge Hub (IDH). This work took place over 18 months between September 2024 and March 2026, during a period of significant transformation across the local health and social care system. 

The Integrated Discharge Hub is an ambitious model designed to address long standing challenges to ‘system flow’. ‘System flow’ refers to how patients move smoothly and effectively through the health and care system. When system flow works well, each stage of our journey — from hospital care to discharge and ongoing support — happens in a timely, coordinated and predictable way. When system flow breaks down, patients experience duplication — such as repeated assessments, repeated questioning, and multiple professionals providing overlapping or conflicting information — alongside miscommunication, longer-than-necessary hospital stays, and fragmented decision-making. 

These challenges have been repeatedly highlighted through system mapping, operational reviews, and years of Healthwatch insight. The Integrated Discharge Hub was established to respond to these issues by bringing together professionals from acute, community, social care, therapy, housing, pharmacy and voluntary sector services into a single, coordinated function. The IDH is supported by unified management and a single point of contact for patients and families. This evaluation sets out the local health and care system’s ambition to develop the IDH as a mechanism for improving system flow and examines to what extent patient experiences reflect those planned improvements. 

Across Milton Keynes, between 1,600 and 2,300 people are discharged from hospital each month. Across the 18-month period, 354 MRNs (patient contacts) were provided to Healthwatch. Only 162 patients were contactable and able to participate.  Despite the smaller-than-intended sample, the consistency of themes across 18 months, across both pathways, and across multiple data sources gives the findings weight.

Across 18-months of insight, they found that patient experience did not show a sustained pattern of improvement. Feedback fluctuated and persistent themes remained. 

Communication was the most influential factor shaping participants’ experience, affecting their understanding, confidence, and preparedness for discharge. Patients on Pathway 2, the intermediate community bed pathway, reported more consistent and positive experiences. Those on Pathway 1, which supports people to return home with care, described much greater variability. 

The findings of this evaluation highlight a gap between system ambition and lived experience, driven largely by inconsistency in communication, coordination, and the delivery of support across multiple services. Addressing this gap is essential if the IDH is to fulfil its potential and deliver a consistently safe, predictable, and person-centred discharge experience.