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Recognising what matters: how real-time shared care records help reduce discharge delays
09 November 2026
Having worked in urgent care, one thing I learnt very quickly is that the hardest decisions aren't always the most clinically complex. Often, they are the ones made with incomplete information. You may have only a few minutes between other patients to decide whether someone needs hospital care, can safely remain at home, or needs support from another part of the system.
In those moments, one missing piece of context can completely change the decision.
It’s not even that the data needs to provide the full answer. Sometimes it must just provide enough to prompt the right questions.
In September 2026, an average of 13,647 patients a day remained in acute hospital care after they were ready to leave.
At the other end of the healthcare pathway, NHS England recorded 99,290 instances of ‘corridor care’ during May 2026, equivalent to around 2,900 a day.
Delayed discharges and avoidable admissions in hospitals are rarely caused by a single issue. Capacity, workforce, care availability, clinical needs, transport and social care circumstances can all affect the movement of patients in and out of hospital.
While shared care records cannot prevent every admission, quicker access to the most relevant information can help professionals decide whether hospital is the right option.
When healthcare professionals can’t quickly establish a patient’s medical or social history, they may need to search different systems, contact other organisations, repeat assessments or wait for further information.
A shared care record that includes and brings together real-time information from primary, acute, community, mental health and social care plays an essential part in establishing the priorities in all areas of clinical judgement.
This can help paramedics quickly access a person’s history and existing care arrangements, so they can decide whether hospital admission is necessary or whether the patient could be supported safely elsewhere.
The aim is not to avoid admission at all costs. It is to reduce the time spent establishing the facts and give professionals greater confidence in the available alternatives.
Information doesn't avoid admissions. Better-informed decisions do. The experience of South Central Ambulance Service shows why that distinction matters. In one case, a clinician attending an older patient following a fall discovered through the Thames Valley Shared Care Record that she had recently undergone hip replacement surgery, information the patient had forgotten to mention.
This new information changed the clinical plan and led to appropriate conveyance for further imaging. In another case, clinicians were able to review previous presentations and ECG information when assessing a distressed patient with chest pain.
For me, this example gets to the heart of clinical intelligence. Technology didn't make the decision and it didn't prevent an admission. It surfaced a piece of information that changed the clinician's understanding of risk. In this case, the safer decision was to convey the patient for further treatment.
This is also relevant to the priorities in NHS winter planning for 2026/27, which include greater use of urgent community response, virtual wards and Hospital at Home, alongside ‘hear and treat’, ‘see and treat’ and referrals to alternatives to emergency departments.
Once a patient is admitted, staff need an accurate view of their wider health and care circumstances to plan treatment and discharge effectively.
Clinicians rarely make decisions from one piece of information. It is much more like assembling a jigsaw. Medication tells you something. Recent admissions tell you something else. A community assessment, a care plan or knowing that a social care package is already in place can completely change what is possible next.
Clinical intelligence comes from seeing those pieces together, rather than discovering them one at a time. The Shared Record, as part of a Care System Platform, is a tool for achieving just that.
As part of a team developing user experience improvements to clinical systems it is fundamental that the solutions that are used by frontline teams provide insight and visibility of key facts rather than just density of data.
This ‘information architecture’ is vital to understanding the holistic picture of the person and interpreting their actual needs; both for the present moment and into the future.
Having this information to hand means less time spent requesting it and allows discharge planning to begin sooner.
This reflects the NHS Model Discharge Pathway, which states that discharge should be treated as a core part of patient care from the point of admission, rather than an activity that begins when the patient is ready to leave.
Teams can then identify what needs to happen next and begin coordinating discharge before the end of the hospital stay.
Discharge is rarely determined by solely from the information held by just one care provider. Depending on the patient’s needs, this may involve GPs, community services, pharmacies, mental health teams, social care and carers.
A shared care record gives these organisations access to the same up-to-date information, making joined-up agreements on next steps easier. Relevant teams can see discharge details, care plans and which services are already supporting the patient without relying solely on calls, emails or handovers. Community and primary care teams can then prepare for follow-up, reducing gaps between hospital and community care.
This approach is already supporting integrated care in St Helens. The Contact Cares multidisciplinary team uses Graphnet’s shared care record to access information across health and social care.
Reported benefits include:
Consistent reduction in delayed transfers of care
Lower growth in non-elective admissions than elsewhere in the region
Prevention of A&E attendance through step-up provision
Improved joint care planning
Graphnet brings real-time admission and discharge data together with social care data, including caseworkers, carers, care plans and existing services. This helps hospital and community teams coordinate around the patient’s wider circumstances, not just the immediate hospital episode.
We sometimes underestimate how much of the burden of fragmented information we place on patients. We effectively ask them to become the integration layer between organisations; remembering what happened at their last appointment, which medication changed, which team is visiting them and what another clinician said.
Systems that operate in silos create extra work for professionals and patients.
For someone who is frightened, acutely unwell, confused or simply exhausted by repeatedly telling their story, that is an unreasonable dependency to build into the way we deliver care.
A shared care record gives professionals access to information already recorded by other services as standard.
In fact, specific patient-centric methods exist within the shared record to capture and make clear not just the diagnostic facts, symptoms or episodes of care, but also the areas that are really important to the individual.
‘About me’ is one such method, enabling patients to record the things that are fundamentally significant to their lives. This can be recorded on their behalf as part of a consultation or by themselves through their patient app. It is also recognised by the Professional Records and Standards Body.
Similarly, the ReSPECT plan records a person’s preferences and clinically agreed recommendations for their care and treatment in an emergency, particularly for when a time comes that they are unable to make or communicate decisions for themselves. This is endorsed by the Resuscitation Council, and they estimate that 80% of English counties are utilising this already.
The shared record is the natural home for this as it provides the access to everyone across a region, and when shared via the national Record Locator Service (NRLS) can even be made available cross-boundary.
Although information will still need to be checked where appropriate, patients are less reliant on remembering and repeating their medical history in order to connect different parts of the system themselves.
NHS England identifies reduced repetition and better continuity between care settings as key benefits of joined-up patient information.
Communicating a complex medical history is easier for some people than others. People with multiple long-term conditions, dementia, learning disabilities, mental health conditions or communication barriers may find it harder to navigate fragmented services.
Giving professionals access to a fuller record reduces reliance on the patient or carer to act as the messenger between services. This can make care more consistent and person-centred, particularly for those supported by several health and social care teams.
Shared data can also help systems understand and address wider inequalities, as explored in our article on reducing health inequalities with shared care records.
A shared care record delivers most value when it is built into workflows across an ICS, as part of a care system platform not simply used to view another organisation’s information. It can support faster decisions, earlier discharge planning, safer handovers and fewer unnecessary requests for information.
It can also give professionals greater confidence in alternatives to admission, improve coordination with community services and support continuity after discharge.
The NHS Model Discharge Pathway links effective discharge flow to reducing prolonged waits for admission and corridor care. This makes information sharing an operational priority as well as a clinical one.
Ultimately, the challenge isn't simply to give care teams access to more information. We already work in a health and care system that generates enormous amounts of data.
The challenge is to turn that information into clinical intelligence: bringing together the pieces that matter, at the moment they matter, so that clinicians can understand the person in front of them and make the safest decision possible.
Sometimes that decision will avoid a hospital admission. Sometimes it will enable an earlier discharge. And sometimes, as the example from South Central Ambulance Service shows, better information will tell us that hospital is exactly where the patient needs to be. That isn't a failure of admission avoidance. It is what good clinical decision-making looks like.
Discover how Graphnet Shared Care can help your ICS connect information across health and social care or contact our team to discuss your requirements.
This article was written by Piers Manser.
With over 26 years of experience in the healthcare sector, Piers is the Chief Clinical Information Officer at Graphnet Health. He set the clinical and strategic direction and company vision across a diverse portfolio, advising the executive board and senior leadership team on product development, design innovation, and clinical governance.
