6. Ayrshire Transformation Board right Care, Right Place Transfer of Care Programme Update FINAL
North Ayrshire Council · 20 August 2026
Back to Integration Joint Board — 20 August 2026 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 20 August 2026 Subject : Ayrshire Transformation Board – Right Care, Right Place Transfer of Care Programme Update Purpose : To update IJB on the Whole System Flow Plan aligned to the Ayrshire Transformation Board Right Care, Right Place programme following completion of the Transfer of Care Business Case and to seek endorsement of North Ayrshire HSCP's contribution to implementation of the agreed programme. Recommendation : The Integration Joint Board is asked to • Note the approval and progression of the Ayrshire-wide Transfer of Care Business Case. • Note confirmation of the conditions to delegate authority to the Chief Officer to progress with operationally implementing plans as described in the update to IJB on 18 June 2026. • Note and endorse the North Ayrshire investment plans supporting delivery of Home First, Discharge Without Delay and Transfer of Care objectives, with agree performance trajectories and planned benefits/improved outcomes • Agree ongoing monitoring through the existing IJB performance and financial reporting frameworks. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required X 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms ATB Ayrshire Transformation Board D2A Discharge to Assess DWD Discharge Without Delay HSCP Health and Social Care Partnership IJB Integration Joint Board NHS AA NHS Ayrshire and Arran PGC Performance Governance Committee
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1. EXECUTIVE SUMMARY 1.1 This report provides the Integration Joint Board with an update on the Whole System Flow Plan, developed through the Ayrshire Transformation Board and NHS Ayrshire and Arran Flow Assurance Board. The Ayrshire Transformation Board (ATB) continues to provide strategic leadership and oversight of whole-system transformation across Ayrshire and Arran. The Right Care, Right Place Programme remains a core component of this work and is focused on improving flow through acute and community services, reducing delays in discharge and shifting the balance of care towards community-based support. 1.2 NHS Ayrshire and Arran continues to experience significant operational pressures, including sustained high hospital occupancy, increasing delayed discharges, Emergency Department congestion and the continued use of non-standard capacity across acute hospital sites. These pressures impact on patient experience, safety, quality of care and the ability of the system to meet performance standards. 1.3 To respond to these pressures, NHS Ayrshire and Arran and the three Ayrshire Health and Social Care Partnerships together with acute services have developed a Transfer of Care Business Case. The Business Case is aligned to national policy including the Health and Social Care Service Renewal Framework, the Discharge Without Delay Programme and national priorities for Unscheduled Care. The Business Case and associated programme of improvement activity is a short term, more immediate approach and seeks to implement a Home First approach through the expansion of community capacity and redesign of discharge pathways. It is recognised that this will not fully address systemic issues and a further and final phase of implementation would be required however is seen as a positive step in shifting the balance of care and realignment of resources into community services. 1.4 At its June 2026 meeting, the IJB agreed delegated authority to the Chief Officer to progress operational plans subject to specific conditions being met. These conditions included formal pan-Ayrshire and system-wide endorsement, recurring funding formally underwritten by NHS Ayrshire and Arran or Scottish Government, assurance that there would be zero financial risk or liability to the IJB, and confirmation that plans would improve outcomes in priority areas including delayed transfers of care and unmet need. This report confirms that these conditions have been fully met and that operational plans have begun progressing towards implementation. 1.5 Phase 2 of the improvement programme, set out in the Business Case, proposes a phased approach to reducing hospital occupancy, improving flow and reducing delayed discharge through investment in community services, intermediate care, rehabilitation and discharge to assess pathways. This will support more people to receive care in appropriate community settings while helping to improve performance and sustainability across the health and social care system.
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1.6 North Ayrshire HSCP has been actively involved in the development of the Business Case and will contribute through expansion of social care capacity, development of discharge to assess pathways, provision of step-up and step-down care and strengthening of community alternatives to hospital admission and prolonged hospital stays. 2. BACKGROUND AND CASE FOR CHANGE 2.1 Health and Social Care services across Scotland continue to face real pressures, including demographics, growing demand, healthcare needs, and increasing financial pressures. Unscheduled care performance, and in particular delayed discharge performance, is utilised as one of the key indicators to measure the efficiency and effectiveness of our health and care system. 2.2 The Scottish Government confirmed £10.079m funding for NHS Ayrshire & Arran in June 2025 for the Operational Improvement Plan aligned to Unscheduled Care, with a programme of initiatives progressed since that time - this is referred to as Phase 1 of the Whole System Implementation Plan. £1.081m was ring-fenced at that time for North Ayrshire to enhance hospital-based MDT capacity (£746k) and Mental Health Officer (MHO) capacity (£335k). This has been fully implemented. 2.3 An Ayrshire Transformation Board has been established in early 2026 by senior partners across Ayrshire to respond collectively to increasing financial, operational and performance pressures across health and social care. The ATB provides a senior officer forum to oversee whole-system transformation, support improved flow, reduce variation and duplication, and progress shared priorities under a “Once-for-Ayrshire” approach. At the core of the initial model are five major programmes: Shared Services/Lead Agency work, Right Care Right Place, Adults with Incapacity (AWI), Digital Transformation, and Communications. Together, these programmes reflect the major areas of system pressure and opportunity identified across the region. 2.4 NHS Ayrshire and Arran has also stepped up a Flow Assurance Board, chaired by the NHS Ayrshire and Arran Chief Executive, to oversee key whole-system improvement areas including Discharge Without Delay, virtual capacity, Adults with Incapacity, integrated discharge hub arrangements, performance and digital, SAFER, the general medicine target model, emergency department operations improvement and mental health flow.
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2.5 Following mobilisation of Phase 1 of the Operational Improvement Plan enacted in 2025/26, the Transfer of Care Programme, referred to as Phase 2 of the Whole System Improvement Plan, has been developed in response to evidence demonstrating that Ayrshire and Arran continues to experience: • Higher than average lengths of stay. • High levels of delayed discharge. • Increased Emergency Department waiting times. • Ambulance turnaround delays. • High occupancy within acute hospitals. • Increased reliance on escalation and non-standard capacity. Day of Care analysis undertaken across Ayrshire and Arran identified that a significant proportion of patients occupying acute hospital beds were clinically ready for discharge but unable to leave hospital due to system constraints. The findings demonstrated that many delays are attributable to challenges across community pathways and social care capacity. NHS AA remains in escalation for financial management, the pressures in acute services, where there are unfunded ward areas and the use of additional patient spaces is contributing significantly to the Health Board’s deficit position. The Business Case sets out a programme of phased investment which will support a programme of acute bed closures and support the Health Board’s financial recovery. 2.6 Within North Ayrshire, it is recognised that the principal factors contributing to delayed discharge and reduced flow include: • Financial resource constraints. • Delays associated with complex discharge planning. • Capacity pressures within Care at Home services. • Availability and choice of care home placements. • Discharge to Assess pathway and capacity constraints. • The impact of meeting the needs of our local population with continued high demand for services. • Adults with Incapacity processes and associated legal requirements 2.7 Without significant improvement in patient flow and transfer of care arrangements, the Ayrshire and Arran acute health care system will continue to experience increasing pressure on capacity, performance and workforce sustainability. The Transfer of Care Programme therefore represents a coordinated whole-system approach to addressing some of these challenges through investment in community capacity and redesign of pathways at the interface between acute and community services.
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3. TRANSFER OF CARE MODEL 3.1 The Transfer of Care Programme is based upon the principles of Home First and Discharge Without Delay. The programme seeks to ensure that people are supported to return home, or to an alternative community-based setting, at the earliest point of clinical readiness wherever it is safe and appropriate to do so. 3.2 Implementation of the programme will be supported through: • Expansion of Discharge to Assess pathways. • Increased community social care capacity. • Enhanced intermediate care and rehabilitation provision. • Strengthened discharge coordination arrangements. • Improved multidisciplinary working across acute and community services. • Greater utilisation of community alternatives to hospital admission and prolonged stays. 3.3 The programme will be delivered through a phased approach: Phase 1 – Stabilisation • Phase 1 of the improvement plan was enacted in 2025/26 and focused whole system improvements on reducing delayed discharge, reducing long length of stays, improving discharge processed and stabilising existing initiatives. Phase 2 – Scaling • Phase 2 of the programme, as described within the business case, enables stabilisation of Phase 1 activity and mobilisation of short term and immediate plans to expand community social care capacity, to further develop discharge pathways and accelerate flow improvements. Phase 3 – Sustainability • Phase 3 of the programme represents the delivery of full system sustainability and the wider transformation that will be required to meet the totality of system demand. Mobilisation of Phase 3 is dependent on the successful delivery of Phase 1 and 2, and will require further development as the next stage of the programme. 4. NORTH AYRSHIRE IMPLEMENTATION PLAN 4.1 North Ayrshire HSCP's contribution to the programme focuses on expanding community social care capacity and strengthening discharge to assess arrangements to support timely discharge and reduce dependence on acute and community hospital provision. These plans have been directly developed through analysis of the specific North Ayrshire challenges and are intended to directly benefit residents of North Ayrshire.
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4.2 The North Ayrshire workstream(s) are focused on expansion of Care at Home and reablement capacity, further development of Discharge to Assess pathways, increased use of intermediate care pathways, development of step-up and step-down care arrangements, access to additional care home capacity where required to support flow and improved integration between acute and community services. This will be delivered through direct investment in the following areas: 1. Additional Care Home Capacity • Investment to secure up to 25 additional care home placements. • This will help reduce delays experienced by people requiring funding for ongoing 24/7 care and support following discharge. 2. Increased Care at Home Capacity • Expansion of Care at Home capacity and Reablement capacity for up to 35 Care at Home packages. • This will support more people to return home safely, linking with the MDT team in the hospital and further promote the Discharge to Assess ethos. 3. Discharge to Assess Step Down beds • Use of the Anam Cara facility, stepping up 5 vacant beds as part of North Ayrshire's integrated discharge pathway. • These beds will provide additional capacity for people who do not require an acute hospital bed but would benefit from further assessment, rehabilitation or recovery support before returning home. 4.3 The North Ayrshire investment plan is expected to deliver benefits for individuals, carers, staff and the wider health and social care system, including: • More people supported to remain at home or return home sooner. • Reduced deconditioning associated with prolonged hospital stays. • Increased access to rehabilitation and recovery-focused support. • Improved patient and carer experience through earlier discharge and reduced transfers between care settings. • Greater utilisation of intermediate care pathways as alternatives to acute admission. • Improved flow through acute hospitals and community services. • Reduced dependence on escalation beds and non-standard capacity. • Better alignment of resources with Home First principles.
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5. PERFORMANCE TRAJECTORIES AND IMPROVEMENT MEASURES 5.1 The Transfer of Care Programme is underpinned by a set of phased improvement trajectories which are intended to demonstrate the expected impact of investment in community capacity, discharge pathways and acute flow. These trajectories provide a framework for monitoring whether the programme is delivering the required improvement in delayed discharge, non-delay discharge activity, Emergency Department performance and ambulance turnaround. 5.2 North Ayrshire Health and Social Care Partnership Trajectories The North Ayrshire trajectories show the expected sustained reduction in delayed discharge levels across both acute and community hospital settings during 2026/27. These trajectories will be used to monitor whether the additional community capacity is supporting improved discharge flow and reducing the number of people delayed in hospital or other care settings. The trajectories have been set by the HSCP based on an assessment of when additional capacity will become available, including factoring in recruitment timescales. North Ayrshire Trajectory Jun 26 Jul 26 Aug 26 Sep 26 Oct 26 Nov 26 Dec 26 Jan 27 Feb 27 Mar 27 Acute Delayed Discharge Trajectory 81 62 67 67 67 58 54 52 50 49 Non-Acute Delayed Discharge Trajectory 48 44 43 42 42 39 38 37 36 36 TOTAL 129 106 110 109 109 97 92 89 86 85 For August 2026, delayed discharge performance within the North Partnership is on target and aligned with the agreed trajectory, with 67 acute delays and 41 non-acute delays recorded for the reporting period. 5.3 NHS Ayrshire and Arran Acute Services Trajectories The acute trajectories provide a broader set of whole-system measures, including non-delay discharges, Emergency Department performance, Scottish Ambulance Service turnaround and daily average 8-hour and 12-hour breaches. These measures are included to ensure performance improvements are assessed across the whole urgent and unscheduled care pathway, not solely through delayed discharge performance.
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Acute Performance Measure Apr- Jun 26 Jul 26 Aug 26 Sep 26 Oct 26 Nov 26 Dec 26 Jan 27 Feb 27 Mar 27 Non-Delay Discharges 178 189 178 170 160 150 140 142 131 120 4-Hour Target 66% 66% 67% 68% 70% 72% 75% 75% 76% 78% SAS Turnaround Time 54.7% 59% 68% 70% 75% 78% 82% 85% 87% 90% 12-Hour Delays, Daily Average Breaches 31 29 25 23 22 18 14 14 12 8 8-Hour Delays, Daily Average Breaches 57 42 38 34 30 26 22 22 12 10 ED performance continued to be challenged throughout July, with overall performance increasing slightly to 54.7% of all patients being admitted, discharged or transferred within 4 hours. This small improvement also resulted in a decrease in 12 hour waits, however there were still 910 across the month, an average of 29 per day, 11 at UHA and 18 at UHC. In the week ending 2nd August, 4 hour performance increased again to 57.8% overall, however 12 hour waits remain high, with an average of 30 per day, 13.6 per day at UHA and 16.4 per day at UHC. These long waits for admission continue to have a direct impact on the assessment and treatment of newly arriving patients, particularly those arriving by ambulance. The most recent SAS operational publication (5th August) shows that Ayrshire and Arran are still above the Scottish median with a turnaround time of 55 mins, compared to 49 mins nationally. Whilst this is an improvement from the previous week (1 hr 4 mins) challenges remain at both sites but particularly at UHC with a median of 58 mins, compared to 49 mins at UHA. 5.4 A reporting and accountability framework will be established to support delivery of the agreed trajectories, and this will be supported by the development of a local reporting framework. Reporting will be aligned through the Performance Governance Committee, Scottish Government Assurance Board, the 3 Integration Joint Boards and Ayrshire Transformation Board. This framework will require clear ownership, escalation routes and evidence of progress against trajectories, including accountability for the Director of Acute Services and Chief Officers in respect of the agreed areas of delivery.
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6. PROPOSALS 6.1 It is proposed that the IJB: • Note the approval and progression of the Ayrshire-wide Transfer of Care Business Case. • Note confirmation of the conditions to delegate authority to the Chief Officer to progress with operationally implementing plans as described in the update to IJB on 18 June 2026. • Note and endorse the North Ayrshire investment plans supporting delivery of Home First, Discharge Without Delay and Transfer of Care objectives, with agree performance trajectories and planned benefits/improved outcomes • Agree ongoing monitoring through the existing IJB performance and financial reporting frameworks. 6.2 Anticipated Outcomes Implementation of the Transfer of Care Programme is expected to deliver improvements across four key domains – Performance, Quality and Safety, Population Health and System Sustainability. 6.3 Measuring Impact Impact will be monitored against the agreed trajectories and delivery milestones included in the approved Right Care, Right Place business case as described in section 5. Regular updates on implementation and performance will be provided and the North Ayrshire IJB will retain responsibility for evidencing impact through its statutory and local governance arrangements. 7. IMPLICATIONS 7.1 Financial The Transfer of Care Programme is supported through a combination of recurring Scottish Government funding, non-recurring transitional funding and planned savings associated with reduced acute bed utilisation. The programme is designed to support a planned transfer of resources from acute services into community-based models of care, facilitating the closure of unfunded acute hospital beds.
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The financial planning identifies the following North Ayrshire Phase 2 investment areas: North Ayrshire Phase 2 Investment Area Planned Capacity 2026/27 Cost Full Year Cost Care Home Places 25 placements £600,000 £800,000 Care at Home / In-house Reablement 35 packages £787,500 £1,050,000 Anam Cara Discharge to Assess Step Down Model 5 placements £274,500 £366,000 TOTAL £1,662,000 £2,216,000 This is in addition to the Phase 1 investment of £1,078k for North Ayrshire which has now been confirmed as recurring investment as part of the business case. Bringing the total additional recurring funding to £3,294k for North Ayrshire. This funding has been confirmed as recurring, and whilst we have signed up to shared plans to deliver on performance improvement which the Partnership are confident to deliver on, the provision of funding is not contingent on the performance improvements being delivered in full. Written confirmation has been received that NHS Ayrshire and Arran will meet the agreed recurrent costs of Phase 1 and 2 delivery and that the IJB and Council will not be liable if the anticipated acute savings, occupancy reductions or efficiency assumptions are not achieved. 7.2 Human Resources Delivery of the programme will require expansion and redesign of community-based workforce capacity alongside changes within acute hospital services. Workforce planning will be undertaken on a phased basis to ensure staffing arrangements remain aligned to service redesign and changing patterns of demand. The programme aims to: • Strengthen community and multidisciplinary services. • Support recruitment to priority services. • Improve workforce sustainability. • Reduce reliance on temporary staffing arrangements. • Promote integrated working across organisational boundaries. All workforce implications will be progressed in partnership with staff representatives and in accordance with relevant workforce governance and consultation arrangements.
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7.3 Legal The Ayrshire Transformation Board and Flow Assurance Board operate within existing statutory frameworks. They do not alter the statutory responsibilities of the IJB, NHS Ayrshire and Arran or North Ayrshire Council. Any decision requiring IJB approval will continue to be progressed through existing IJB governance routes. 7.4 Equality/Socio-Economic The programme supports the delivery of care closer to home and seeks to reduce the adverse impact associated with prolonged hospital stays, particularly for older people, people with frailty and individuals with complex care needs. The Home First approach promotes independence, rehabilitation and recovery within community settings and aims to improve outcomes and experiences for individuals and carers. Equality and socio-economic impacts will continue to be monitored and assessed as individual service changes are developed and implemented. 7.5 Risk Key risks associated with implementation of the Transfer of Care Programme include: • Community capacity not increasing at the pace required to support discharge trajectories. • Recruitment and workforce challenges impacting service mobilisation. • Delays in implementation of Discharge to Assess pathways. • Ongoing Adults with Incapacity and legal process delays. • Failure to achieve anticipated reductions in delayed discharge and length of stay. • Failure to realise planned reductions in acute bed utilisation. • Financial sustainability risks should recurring funding not be maintained. • System-wide dependencies requiring coordinated delivery across NHS Ayrshire and Arran and all three HSCPs. • Cultural and operational change associated with implementation of Home First approaches. Whilst increased community capacity is expected to improve discharge performance and flow, implementation may also generate increased demand for community assessment, rehabilitation and reablement services as pathways mature and confidence increases. Monitoring arrangements will therefore include measures relating to referral volume, response times, caseloads, throughput and service capacity to ensure that community services remain able to deliver intended outcomes while sustaining performance trajectories.
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These risks will continue to be monitored through established governance arrangements including the Ayrshire Transformation Board, NHS Ayrshire and Arran Flow Assurance Board and local IJB governance structures. 7.6 Community Wealth Building There are no direct Community Wealth Building implications arising from this report. Where additional local capacity is commissioned or developed, opportunities to support local procurement, workforce wellbeing and community benefit should be considered. 7.7 Key Priorities The plan supports strategic priorities to shift the balance of care, reduce reliance on acute hospital provision, improve unscheduled care performance, reduce delayed transfers of care and strengthen community-based alternatives. It also aligns with the IJB’s role in ensuring that delegated health and social care functions are planned and delivered in a way that improves outcomes and makes best use of available resources. 8. CONSULTATION Senior officers from North Ayrshire Council, North Ayrshire IJB and NHS Ayrshire and Arran have been involved in development of the proposals through the Ayrshire Transformation Board and NHS Ayrshire and Arran Flow Assurance Board arrangements. Further engagement is ongoing with operational services, staff, partners and governance forums as implementation plans and the reporting and accountability framework are progressed. Caroline Cameron, Director / Chief Officer Author: Kerry Logan, Head of Service (Health and Community Care) Appendices • Appendix 1 - RCRP Business Case
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Page 1 of 24 Paper 06p Right Care Right Place
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Page 2 of 24 Ayrshire and Arran Delivering Right Care, Right Place: Transfer of Care Business Case 1.0 Introduction NHS Ayrshire and Arran is experiencing sustained system pressure, including high occupancy, delayed discharges, Emergency Department (ED) congestion and insufficient community capacity. These pressures are resulting in escalating patient safety risks, use of non-standard capacity, and challenges in delivering timely, person-centred care across both acute hospital sites. This business case seeks approval for a whole-system transfer of care model, requiring Health and Social Care Partnerships (HSCPs) to expand community-based alternatives to admission and discharge. This will support a planned and sustained reduction in acute hospital occupancy, aligned to the Unscheduled Care Operational Improvement Plan and national policy direction. 2.0. Purpose and Context 2.1 National Context This proposal aligns with: • The Health and Social Care Service Renewal Framework • The Top 10 Priorities for Unscheduled Care (2026/27) • The Discharge Without Delay (DWD) programme Collectively, these policies prioritise a shift in the balance of care from hospital to community, with a focus on improving flow, reducing delays, and delivering care closer to home. Figure 1 – Health and Social Care Strategic Objectives
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Page 3 of 24 Figure 2 – Top 10 Areas of Focus for Unscheduled Care Figure 3 – DWD Principles and Priorities
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Page 4 of 24 2.2. Local Context - Ayrshire and Arran Unscheduled Care Ayrshire and Arran has been identified as an outlier across a number of key indicators, including: • Higher than average length of stay (LOS) • High levels of delayed discharges • Increased ED waits and ambulance delays • High bed occupancy, particularly in frailty and medicine pathways The Centre for Sustainable Delivery (CfSD) has supported improvement activity since 2023, highlighting the need for system-wide redesign. Progress has been made across key areas; however, sustained improvement is constrained by limited community capacity and whole-system integration challenges The improvement actions from the CfSD Discovery exercise carried out late 2024 are set out below in Table 1 with a current update position. Table 1 - CfSD Recommendations: Summary of Current Position Recommendation Current Status / Position 1. Develop a Realistic Care Improvement Programme A 3-year Realistic Care Improvement Programme launched in April 2025. Progress includes divisional transactional programmes, unwarranted variation projects, income generation initiatives, reduction in unnecessary tests, SAFER rollout acceleration, and specialty-level reviews to improve quality, performance, and productivity. 2. Strengthen strategic and operational system relationships Key processes (e.g. MDT board rounds, LOS reviews) reset at Crosshouse with escalation to HSCP. Progress constrained by financial recovery pressures and high occupancy. Whole Systems funding supporting delayed discharge reduction and capacity improvements. Engagement strengthened via DWD programme and system-wide working. Frontline awareness is high; however, empowerment and culture change require further development. Data and digital tools (e.g. Shrewd platform, dashboards) improving visibility and performance monitoring. 3. Focus on improving patient journeys Being advanced through the multi-agency DWD programme. Work commenced May 2025 with continued engagement sessions and workshops aligned to the Whole Systems Operational Improvement Plan. Improvement resources in place for priority areas such as frailty pathways (linked to HIS workstream). Progress ongoing with strong multiagency involvement. 4. Create meaningful data packs for frontline teams Unscheduled Care (USC) dashboards and data packs developed and routinely shared via Performance and Flow Board. BI support enables analysis of trends and variation. Ward-level data (e.g.
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Page 5 of 24 LOS, discharge metrics) established in line with Discharge Without Delay principles. Foundations in place with further refinement underway. 5. Socialise and finalise vision and high-level aims Vision statement co-produced through leadership engagement. Decision taken to align formal launch with Whole Systems Improvement and DWD programmes to maximise impact. Positioned to support multidisciplinary working and delivery of a person-centred, “care closer to home” model. 2.1 Operational Improvement Plan In June 2025, the Scottish Government confirmed £10.079m of non-recurring funding for NHS Ayrshire & Arran to support delivery of the Unscheduled Care Operational Improvement Plan. This allocation was lower than the original submission, which had been developed to fully deliver the agreed objectives. A programme of initiatives has been in progress since late 2025/26. For the purposes of this business case, this initial period is described as Phase 1. The non-recurring nature of the funding has, however, constrained the organisation’s ability to recruit to posts and to mobilise services that require recurrent investment to be sustainable. Additional detail for Phased 1 plans is detailed in Appendix 1 to provide additional background in context of the plans set post funding allocation in August 2025. As a result, while Phase 1 activity has supported progress in specific areas, it has not delivered operational improvement at the scale or pace required to release recurring resource or to materially address the ongoing quality, safety and flow challenges within acute hospital settings across Ayrshire and Arran. The recurring funding requirement to fully deliver Phase 1 is estimated at £4.6m, against an identified recurring budget of £3.2m. There is sufficient funding to support delivery in 2026/27, primarily as a result of in-year slippage; the shortfall along with phase 2 investments will be the first call on acute bed closure savings subject to confirmation of any additional resources in 2027/28. 3.0 Case for Change This section provide the rationale and evidence on why this change is needed to improve pathways and processes across the interface, improve delayed discharges, and reduce length of stay. There are significant challenges facing the EDs and wards on both hospital sites with crowding of patients and this impacts staffs’ ability to provide dignified person-centred care. Addressing the lack of flow through and out of the acute sites is a must for the organisation. 3.1 Current pressures are creating significant risks including: • Patient deterioration and deconditioning associated with prolonged hospital stays • Overcrowding in ED and extended waits for assessment and admission
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Page 6 of 24 • Use of non-standard care areas, impacting dignity, privacy and safety • Delays in ambulance offload, increasing risk to patients in the community • Inability to meet key national standards for stroke, critical care and paediatric pathways • Workforce fatigue and challenges with recruitment and retention 3.2 Performance Case for Change Performance remains below national standards, driven by high occupancy and delays in discharge. This impacts: • ED 4-hour and 12-hour performance • Length of stay across key specialties • Hospital flow and patient experience A consistent approach across both acute sites has reduced variation; however, system pressures continue to limit sustained improvement. Appendix 2 provides the supporting performance data for the Transfer of Care Business Case. It outlines key trends across urgent and unscheduled care, including Emergency Department performance, ambulance flow, occupancy, length of stay and delayed discharges. Collectively, the data demonstrates the scale, trajectory and underlying drivers of current system pressures. Outlined below are critical factors highlighting the challenges of the three HSCPs. The tables below show poorer health outcomes for Ayrshire and Arran residents, the variation across HSCP areas and the different solutions to meet local population need. Metric East North South Ayrshire & Arran Scotland Population (000s) 121.5 134 112.3 367.8 5,546.90 Population Share (%) 33.00% 36.40% 30.50% 100% — Over 65s (000s) 25.2 30.9 28.9 85 1,067.00 % Aged 65+ 20.70% 23.00% 25.80% 23.10% 19.20% Population in the Least Deprived (SIMD %) 10.90% 9.70% 19.60% 13.10% 20% Population in the Most Deprived (SIMD %) 30.60% 40.90% 16.70% 30.10% 20% Working Age (16–64, 000s) 76 82.3 66.6 224.9 3,583.00 % Working Age 62.60% 61.40% 59.40% 61.20% 64.60% Male Healthy Life Expectancy (years) 55.8 52.6 58.4 55.4 59.6 Female Healthy Life Expectancy (years) 55.4 52.5 58.9 55.3 60 Children (0–15, 000s) 20.3 20.9 16.7 57.9 896.8 % Under 16 16.70% 15.60% 14.90% 15.70% 16.20% Looked After Children (per 1,000) 18.2 16.9 10.2 — 11.7
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Page 7 of 24 This case for change incorporates the change required to shape service redesign from varying service profiles which will need to improve outcomes and experiences for patients, staff and the wider health and care system. 3.3 Whole System Analysis (Day of Care Insight) Day of Care audit findings highlight a fundamental mismatch between acute capacity and patient need, with over a quarter of inpatients clinically ready for discharge but unable to leave hospital. South HSCP – key drivers of delay: • Limited Care at Home capacity • Delays in social work assessment and decision-making • Access to step-down and rehabilitation provision • Legal and placement processes North HSCP – key drivers of delay: • Delays associated with complex discharge planning, including Discharge to Assess (D2A) pathways and social work assessment • Limited community social care capacity (including Care at Home and care home placements) • Access to step-down and rehabilitation provision • Adults with Incapacity considerations, including requirements of associated legal processes East HSCP – key drivers of delay: • Social care capacity in the care home sector which impacts on flow across the system • Flow through social care itself in transitions home from hospital, through reablement and on to locality care at home • Persistent legal, guardianship and decision-making processes (including AWI) which slow discharge pathways • Insufficient community health capacity in district nursing and East Ayrshire Community Hospital to create further flow and rehabilitation/end of life resource Collectively, these factors indicate that current pressures are driven by system-wide capacity and process constraints, rather than hospital demand alone.
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Page 8 of 24 Delivery of the planned delayed discharge reduction trajectories for September and December 2026 is dependent on timely mobilisation of Phase 1 activity from early July 2026. There is a direct link between pace of implementation and delivery of trajectory milestones. Any delay to approval or mobilisation will impact the system’s ability to deliver these trajectories and realise the benefits associated with the proposed investment. 3.4 Financial Case for Change Overcrowding across the front doors is driving a financial overspend across both sites. Both the Emergency Departments regularly require additional staffing to care for the higher volume of patients safely as well as an increase in the number of one-to-one supervisions for frail and vulnerable patients. Length of stay across both acute hospital sites continues to challenge the organisation financially with unfunded wards filled with medically fit patients/ delayed discharges waiting on packages of care, placement, or step down community bed provision. Length of stay within the HSCP led community sites are also challenging leading to unavailability of downstream beds, lack of flow as associated costs. It is acknowledged there are financial pressures for the HSCPs, although these do not carry the same risks relating to clinical quality and safety being escalated on a regular bases from staff and staff side colleagues on a regular basis. Without accelerated whole-system transformation, including improved partnership working, seven-day services, reduction in delayed discharges, and investment in community-based alternatives, acute capacity will remain constrained. A coordinated, pan-Ayrshire approach is therefore essential to deliver sustainable improvement, reduce inequalities, and shift care closer to home for an increasingly complex and ageing population 4.0 Proposal This proposal sets out a structured and phased approach to redesigning service delivery across acute and community settings in Ayrshire and Arran. It responds to sustained system pressures by focusing on improving patient outcomes, experience and flow, while establishing a more sustainable and integrated operating model aligned to national policy and local population needs. 4.1 Approval Required Approval is sought for a combined Phase 1 and Phase 2 investment and delivery approach to the Unscheduled Care Programme, recognising that: • Phase 1 requires confirmation of recurring funding to sustain and stabilise existing service developments initiated through non-recurring investment • Phase 2 requires approval to proceed at pace and scale to deliver whole-system transformation and achieve the agreed performance trajectories
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Page 9 of 24 Approval is therefore requested to: • Enable immediate mobilisation across both phases, recognising that delivery of the September and December 2026 trajectories is dependent on implementation commencing from early July 2026 • Support the transition to a sustainable, whole-system Transfer of Care model, shifting the balance of care from acute hospitals to community-based provision • Approve the phased transfer of resources from Acute Services to HSCPs, explicitly linked to improvements in flow, length of stay and delayed discharge performance • Approve the planned and controlled reduction in acute bed capacity, including ward closures, with associated reinvestment of released resource into community services on a recurring basis as detailed in the phase 1 and 2 commitments. This approval establishes the financial and operational framework required to deliver a safe, paced transition, ensuring that community capacity is developed in advance of, and alongside, reductions in acute capacity, in line with the phased delivery model set out in this business case. Given the complex landscape in which this business case is presented, the following conditions have been stipulated by Ayrshire Integration Joint Boards (IJBs) in progressing implementation in order to provide sufficient levels of assurance: • The Plan has pan-Ayrshire and system-wide support and is formally endorsed at a meeting of the Ayrshire Transformation Board. • Funding is provided on a recurring basis, with assurance that this is formally underwritten by NHS Ayrshire and Arran or Scottish Government. This ensures there is zero financial risk or liability to the IJBs. • HSCPs are assured that plans will target improvement in performance and patient outcomes in areas of priority for the IJBs, including delayed transfers of care and unmet need. • This business case is finalised and brought back to the IJBs following the summer recess. 4.2 Models of Care The proposal is aligned to the principles of the national Discharge Without Delay programme and supports the consistent adoption of a Home First approach across Ayrshire. This approach recognises and prioritises the importance of sufficient social care capacity within our communities. It will enable individuals to be discharged at the earliest point of clinical readiness and, wherever possible, to be assessed within their usual place of residence.
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Page 10 of 24 Delivery will be supported through: • Discharge to Assess (D2A) pathways • Expansion of community social care capacity • Enhanced Intermediate care and rehabilitation provision • Strengthened discharge coordination arrangements 4.3 Phased Delivery Approach Delivery will follow a structured, phased trajectory: • Phase 1 (Stabilisation): Reduce delays and long stays through targeted interventions and improved discharge processes • Phase 2 (Scaling): Expand community capacity and embed new pathways • Phase 3 (Sustainability): Achieve safe reduction in bed capacity and long-term system redesign Phase 3 represents the delivery of full system sustainability and the wider transformation required to meet the totality of system demand. It will require further development of detailed plans beyond phases 1 and 2, including optimisation of community hospital provision, mental health inpatient pathways, and preventative community-based supports. Any movement to a Phase 3 model will be dependent on all stakeholders delivering the benefits articulated within this case. Phase 3 will therefore be developed as the next stage of the programme, building on the foundations established through phases 1 and 2, and will be brought forward for further approval as detailed plans and funding arrangements are confirmed. This will enable a progressive reduction in acute bed base, aligned to improvements in flow and performance which is sustainable. 4.4 Improvement Trajectory The programme will deliver: • Reduction in length of stay across key pathways • Reduction in delayed discharges towards national benchmarks • Improved ED flow and elimination of extended waits • Increased discharge rates and improved ward productivity
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Page 11 of 24 4.5 Whole System Transformation Area Key Actions Outputs Impact / Benefit Financial Value East HSCP Enhance community rehabilitation, enablement and advanced practice capacity through: Allied Health Professional capacity within ICT; Increase social care capacity to support flow; Advanced practice and Mental Health Officer support; Care home placements to address flow. Increased discharge capacity, improved flow capacity, improved rehabilitation and enablement availability. Further leverage from existing resource through investment addressing key reasons for delay identified in Scotland (awaiting community support, care home place, assessment/reassessment, equipment/adaptation or family choice). Accelerate flow to enable response to higher acuity needs Reduce unnecessary hospital stays and delayed discharge Increase availability of appropriate useable acute beds/reduce occupancy of high-cost acute capacity Impact on reduced average length of stay Prevention of avoidable admission Enabling functional recovery North HSCP Expansion of community social care capacity and strengthening of discharge to assess pathways including step up/step down and intermediate care Increased availability of community- based care, enhanced utilisation of D2A and intermediate care capacity, improved flow through hospital and community settings Reduction in delayed discharges and overall length of stay, improved outcomes and experience for individuals through timely, person centred discharge and more effective use of hospital capacity Significant cost avoidance through reduced bed days and improved system flow, opportunity to reinvest in sustainable community- based models of care South HSCP Enhanced intermediate care provision; Strengthening of discharge to assess pathways; Advanced practice and nursing resource to support IC and Home First approaches; Moving and Handling, appropriate access to equipment and Increased availability of community based care, access to IC beds, strengthening of pathways to facilitate discharge to assess, expanded care at home capacity, improved access to appropriate equipment, home first Increased discharge capacity and improved flow Reduction in delayed discharges and length of stay; improved outcomes for service users and carers. Efficient use of local resources – community based services aligned to community led supports Care closer to home; financially more sustainable in comparison to acute based care Workforce investment; financial impact from workforce growth/development linked to wellbeing.
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Page 12 of 24 person centred care. approach and linkage with acute frailty and community frailty pathways. Acute Services Address gap in service provision with 7 days frailty and COTE MDT workforce provision including psychology and AHP. Key focus on admission avoidance and timely interventions. Admission avoidance, CGAs to support system wide care delivery, 7 day AHP front door and assessment provision. Integrated discharge planning on admission to assessment units. Improved flow and discharge rates Delivery against Emergency Care Standards, GIRFE, achieve frailty standards, improve flow, reduce LOS and as a result reduce occupancy and patient safety risks arising from high occupancy Releases recurring acute costs aligned to reduced bed utilisation Whole System Resource shift/integration - Rebalancing investment towards community- based provision, with strengthened integration across health and social care services Community alternatives established - Expanded community social care capacity, Discharge to Assess (D2A) pathways, and intermediate care enabling Home First delivery Reduced hospital utilisation - Indicative reduction of approximately 129 hospital beds through improved flow and reduced delayed discharge Long-term sustainability - More sustainable whole- system model, supporting improved outcomes, reduced reliance on acute capacity, and system-wide cost avoidance The detailed trajectories against each phase of the investment areas, with timelines for delivery and bed closure plans are included as Appendix 3. Delivery of the delayed discharge reduction trajectories for September and December 2026 is contingent on plans being progressed and mobilisation commencing in early July 2026. Any delay to this timeline will directly impact the ability to deliver in line with the trajectories set out in the appendices. 5.0 Workforce Implications The delivery of the proposed phased reduction in acute bed capacity, alongside the expansion of community-based services, has significant workforce implications across NHS Ayrshire and Arran and partner HSCPs. These changes are aligned to the NHS Scotland policy direction, which supports a shift in the balance of care from hospital to community, improvement in patient flow, and delivery of care closer to home.
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Page 13 of 24 Across both acute hospital sites, there are existing vacancies and workforce pressures within nursing and medical staffing establishments. These vacancies, alongside anticipated natural turnover, provide an opportunity to support a planned and managed transition to a reduced inpatient bed base, avoiding the need for large-scale workforce displacement while maintaining safe staffing levels and service continuity. The phased nature of this programme allows time to undertake structured workforce planning between now and the implementation of ward closures, enabling: • alignment of workforce capacity to a smaller, more clinically appropriate inpatient footprint • use of natural attrition and vacancy management to support workforce realignment • redeployment of staff to priority areas, including front door services, frailty pathways, and community interfaces • strengthening of workforce models in areas critical to Discharge Without Delay (DWD) and Home First delivery For nursing workforce, the reduction in both core beds and non-standard escalation capacity will support a transition towards more sustainable staffing models, consistent with Health and Care (Staffing) (Scotland) Act 2019 principles, including: • improved alignment between staffing levels and patient need • reduced reliance on bank and agency staffing, particularly where non-standard beds have required staffing outwith established workforce models • improved working conditions and patient care environments For the medical workforce, the planned reduction in inpatient capacity provides an opportunity to review and optimise Consultant job plans across both hospital sites. This will support: • increased senior decision-making presence within remaining inpatient wards • more timely clinical review, discharge planning, and escalation • improved multidisciplinary team working, supporting patient flow and reduced length of stay Workforce planning will be undertaken in line with NHS Scotland workforce governance expectations and will be delivered through a phased, clinically-led approach, ensuring: • workforce changes are aligned to service redesign and capacity changes, not in advance of them • safe staffing levels are maintained at all times, with oversight through appropriate governance arrangements • workforce risks are actively managed through programme and Board-level assurance structures All workforce planning and implementation will be progressed in full partnership with Staff Side organisations and in collaboration with the operational and professional leads for each area.
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Page 14 of 24 This will ensure that all changes are: • professionally led and clinically safe • compliant with national workforce policy and legislation • informed by appropriate engagement, consultation, and communication processes This programme presents an opportunity not only to align workforce to a more sustainable model of care, but also to deliver against wider NHS Scotland ambitions to: • improve staff experience and wellbeing • reduce reliance on temporary staffing • strengthen integrated, multidisciplinary working across health and social care Overall, the proposed approach supports a managed transition of workforce aligned to system transformation, ensuring that staffing models evolve in parallel with the shift towards a Home First, community-focused model of care, while maintaining patient safety, service quality, and workforce sustainability. 6.0 Financial Implications The financial model underpinning the Transfer of Care programme has been developed to provide clear line of sight between investment, delivery of capacity, and the release of recurring savings, ensuring that the proposed transformation is both affordable and low risk at a system level. The programme requires targeted pump-priming investment to expand community services and enable transformation. The model represents a shift from high-cost reactive care to more efficient, preventative community-based provision, delivering long-term financial sustainability. This investment will: • Support safe reduction in acute bed utilisation • Release recurring acute costs • Enable reinvestment across the system 6.1 Funding Position and Profile The programme is supported by a combination of Scottish Government funding, non- recurring carry forward (in 2026/27), and planned system savings, providing a robust funding envelope across the transition period. Total resourcing for 2026/27 is £10.2m, rising This includes: - £3.2m recurring Scottish Government funding aligned to Unscheduled Care priorities - £4.0m non-recurring carry forward supporting transition and pump-priming investment - £2.2m indicative additional funding from 2027/28 - £3.0m–£8.8m of gross savings from acute bed closures, which support the reinvestment in out of hospital services and financial recovery within the Health Board
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Page 15 of 24 6.2 Investment Requirements (Spend Profile) The programme requires targeted investment across Phase 1 and Phase 2 to expand community capacity, improve flow, and enable the shift to a Home First model. Total planned spend is £10.2m in 2026/27, reducing to £9.3m on a recurrent basis. 6.3 Savings and Cost Avoidance The financial model is predicated on the progressive release of savings from reduced acute bed utilisation, aligned to improvements in flow and length of stay. The programme supports a total reduction of approximately 129 beds across the acute system, delivered through a combination of whole-system improvements and acute service redesign. Failure to deliver these bed reductions all other things being equal leaves a deficit for the health board to fund of £3m in 2026/27 rising to £4m in 2027/28. Of these, 98 beds are directly linked to the delivery of delayed discharge reduction trajectories and are supported by clearly identified financial savings of £3.0m in 2026/27, rising to £8.8m recurrently. These reductions are dependent on the successful expansion of community capacity and delivery of the Transfer of Care model, enabling patients to be discharged at the point of clinical readiness. The remaining 31 beds relate to non-standard capacity, including escalation beds and additional ward spaces that are routinely opened to manage congestion and variability in demand. The planned reduction of these beds will be achieved through improvements within acute services, including reduced length of stay, more timely clinical decision- making, and improved flow across the inpatient pathway within the financial year. While these 31 beds are not associated with a defined recurrent budget line, they are sustained in practice through increased reliance on bank and agency staffing, reflecting their position outside established ward baselines. As these beds are removed, a corresponding reduction in premium staffing costs is expected, and this will be closely monitored to ensure delivery of the anticipated financial and operational benefits. Taken together, this approach provides a balanced and deliverable plan, where: • 98 beds are released through whole-system change and community capacity expansion, and • 31 beds are released through improved efficiency and patient flow within acute services This ensures that the overall bed reduction is both clinically safe and operationally achievable, while supporting improved patient outcomes, reduced overcrowding, and more sustainable use of resources.
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Page 16 of 24 The full funding profile is noted in the table below. 6.4 Overall Financial Position The programme delivers a managed transition from short-term pressure to recurrent sustainability. While 2026/27 reflects a break even in-year position due to the timing of the phased bed closures, a recurring surplus of approximately £4.8m is achieved as transformation benefits are realise, as the Health board is underwriting the IJB’s risk in terms of funding these commitments recurrently the surplus is used to support Health Board financial recovery. The expenditure in phase 2 is assumed to be a nine month in year spend. Late commencement of much of this is likely and this could generate slippage. 6.5 Financial Risk and Assurance The model minimises financial risk through phased investment, conditional bed closures, managed double running, and clear linkage between savings and deliverable service changes. Overall, the programme demonstrates a financially viable and sustainable model, providing assurance that investment will translate into measurable, recurring benefits while maintaining control of financial risk. Funding will be released on a monthly basis subjected to confirmation of associated spend and recruitment activity where applicable as identified in the plan. 7.0 Outcomes and Benefits The programme will deliver measurable improvements across four key domains as outlined below and set out in more detail within Appendix 2. Financial profile East North South Acute Total 26/27 Total Recurring Phase 1 400 258 688 380 1,725 - Phase 2 300 300 - Total Non-recuring costs 400 258 988 380 2,025 - Phase 1 883 1,078 1,180 1,526 4,667 4,667 Phase 2 (9 months 26/27) * 678 1,662 1,148 3,487 3,487 Total Recurring costs (26/27) 1,561 2,740 2,327 1,526 8,154 8,154 Phase 2 (FYE of the 9 months above) 226 554 383 - 1,162 Total Committed Recurring costs (27/28 onwards) 1,787 3,294 2,710 1,526 8,154 9,317 TOTAL COSTS 2,187 3,552 3,698 1,906 10,180 9,317 Funding Available (£000'S) Total 26/27 Total Recurring Non-recurring carry forward 3,986 SG allocation 3,200 3,200 Additional 27-28 SG £30m investment 2,175 Total bed closure savings 3,020 8,807 TOTAL FUNDING - - - - 10,206 14,182 BALANCE (retained) 26 4,865 £000's
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Page 17 of 24 Performance • Reduced length of stay • Improved ED performance • Reduction in delayed discharges Quality and Safety • Reduced overcrowding and corridor care • Improved dignity and patient experience • Reduced harm from prolonged stays Population Health • Increased independence • More care delivered at home • Reduced reliance on institutional care System Sustainability • Reduced acute bed dependency • Improved workforce utilisation • Better alignment to safe occupancy levels 7.1 Quality, Safety and Cost Avoidance Benefits The proposed reduction of 129 beds represents a significant quality improvement opportunity and a substantial source of cost avoidance across the whole health and social care system. Current data demonstrates that patients who are clinically ready for discharge can experience prolonged delays whilst awaiting care at home packages, social work assessment, guardianship processes, rehabilitation or longer-term care arrangements. Across Ayrshire and Arran, delays associated with care at home provision range from 5.8 to 37.2 days, whilst delays associated with social work and guardianship processes range from 33.6 to 65.6 days. Consequently, many individuals remain within an acute hospital bed for between one and two months after they have been deemed medically fit for discharge. Prolonged hospitalisation is associated with a range of recognised and avoidable harms including deconditioning, falls, pressure ulcers, healthcare associated infections (HAIs), loss of independence and deterioration in physical and cognitive function. These harms are particularly significant for frail and older people and can result in increased dependency, poorer outcomes and a greater likelihood of requiring ongoing care and support following discharge. National evidence demonstrates that pressure ulcers can increase hospital length of stay by up to 10 days and incur substantial treatment costs, whilst falls continue to represent one of the most significant causes of avoidable harm for
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Page 18 of 24 older adults. Importantly, Scottish evidence estimates that approximately 60% of the total costs associated with falls are borne by social care services through increased care needs, care home placements and long-term support requirements. Reducing delayed discharges and supporting earlier transfer of care will therefore deliver benefits that extend well beyond the release of acute bed capacity. Earlier discharge to the right care setting will reduce exposure to hospital-associated harm, maintain independence, support rehabilitation and improve patient experience and outcomes. It will also reduce the risk of escalation in care needs, thereby avoiding additional costs across both NHS Ayrshire & Arran and the three Health and Social Care Partnerships. There is also a direct link between reduced length of stay and infection prevention. NHS Ayrshire & Arran's Infection Prevention and Control review estimates that healthcare associated infections account for approximately 6,758 excess bed days annually and cost in excess of £5.4 million per annum. Extended hospital stays increase patients' exposure to infection risk, antimicrobial treatment and associated complications. By reducing unnecessary hospital days and improving patient flow, the Transfer of Care model will contribute to reducing infection risk, avoiding excess bed days and supporting safer, more effective care. Taken together, the reduction in delayed discharges should be viewed as a whole-system quality and safety intervention that delivers recurring cost avoidance through reduced hospital-associated harm, lower treatment costs, reduced demand for long-term care, improved utilisation of acute and community resources and better outcomes for the population of Ayrshire and Arran. The anticipated benefits will be realised across both health and social care through improved patient flow, reduced dependency, enhanced independence and a shift in the balance of care towards community-based support in line with the Health and Social Care Service Renewal Framework. 8.0 Risks and Mitigations The delivery of the proposed transfer of care model represents a significant whole-system transformation and, as such, carries a number of strategic, operational and financial risks. These risks have been carefully considered within the development of the business case, and mitigating actions have been embedded within the programme design, phased delivery approach, and governance arrangements. 8.1 Strategic and Operational Risks A key risk relates to the ability of community services to scale at the pace required to support increased discharge volumes and the shift towards a Home First model. The business case explicitly recognises that current system pressures are driven by whole- system constraints, particularly limited Care at Home capacity and delays in social care provision. To mitigate this, a phased delivery approach has been adopted, ensuring that increases in discharge activity, including the planned expansion of Discharge to Assess (D2A), are aligned with demonstrable increases in community capacity. Investment in Care at Home, intermediate care and reablement services forms a core component of the proposal, and
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Page 19 of 24 progression to acute bed reduction will be conditional on evidence of sustained improvement in flow, length of stay and delayed discharge performance. Daily MDT and IDT processes will provide real-time oversight of patient flow, with escalation through the Flow Assurance Board where constraints are identified. A related risk is the ability to deliver consistent seven-day working across both acute and community services, which is essential to improving patient flow and enabling timely discharge. The programme addresses this directly through the development of Acute Frailty Units operating on a 7-day basis, enhanced weekend discharge processes, and planned consultant job plan changes in Phase 2. These changes are aligned to Discharge Without Delay principles and will be monitored through performance metrics including weekend discharge rates and length of stay variation. Workforce capacity represents a further critical risk, particularly in relation to AHP provision, frailty services, and community-based care delivery. The business case includes a defined workforce plan, with recruitment to Phase 1 posts already underway and a clear focus on addressing gaps at the front door, in frailty pathways and within the medicine bed base. Alongside recruitment, the programme incorporates workforce redesign, including new roles and skill mix changes, to support sustainable delivery. Workforce assumptions and risks will be routinely reviewed through programme governance to ensure alignment with activity and demand. The reduction of the long length of stay (LLOS) cohort is a key enabler within Phase 1, but also presents risk given the complexity of these patients, including legal, housing and care placement challenges. This risk is being mitigated through a targeted, system-wide approach, including dedicated oversight of the top 75 LLOS patients across all three HSCPs, supported by regular review and escalation processes. This work is integrated with the wider Discharge Without Delay programme, ensuring earlier identification and proactive management of delays. Effective implementation of Integrated Discharge Teams (IDTs) is also critical. There is a risk that without consistent application of MDT board rounds and clear accountability for discharge decisions, delays and duplication may persist. To address this, the programme includes a standardised operating model aligned to DWD principles, supported by ward- level performance data, routine LOS reviews at 72 hours and 7 days, and strengthened clinical leadership. These arrangements will ensure discharge planning is embedded as a core component of daily clinical practice. Digital and information sharing constraints are recognised as a further risk, particularly given current system fragmentation and the impact this has on timely discharge planning. The business case outlines ongoing work to improve data visibility, including the development of dashboards and meaningful data packs for frontline teams. This will be supported through a dedicated digital workstream, ensuring improved access to real-time information and consistent documentation across the system. Finally, there are inherent patient safety risks associated with implementing a D2A / Home First model, particularly for individuals with complex needs or where community capacity is under pressure. These risks will be mitigated through robust multidisciplinary assessment,
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Page 20 of 24 the use of Comprehensive Geriatric Assessment within frailty pathways, timely capacity assessments, and access to 7-day community support. Patient outcomes, including readmissions and experience, will be closely monitored to ensure that the model delivers safe, person-centred care. 8.2 Financial and Resource Risks A critical risk for the programme relates to the transfer of financial resources from Acute Services to HSCPs, which underpins the shift in the balance of care. There is a risk that funding may be insufficient, non-recurrent, or not aligned to actual demand, potentially leading to financial instability within HSCPs and an inability to sustain community capacity. The business case directly addresses this through a phased and planned transfer of resources, linked to delivery of service change and capacity expansion. Financial risk associated with delivery does not sit with the IJBs provided that the recovery trajectories identified are achieved. Financial modelling has been developed to demonstrate how reductions in acute bed utilisation will release resources for reinvestment in community services. Importantly, no significant reduction in acute capacity will be undertaken without assurance that community capacity is in place and sustainable, ensuring that risks associated with cost shunting or system destabilisation are minimised. There is also recognition of double running costs during the transition period, where both acute and community services may need to operate in parallel. This has been built into the financial planning assumptions, with pump-priming investment identified to support the transformation phase. This is expected to be time-limited, with clear trigger points linked to flow improvements and bed reduction milestones. A further financial risk relates to the ability to realise cash-releasing savings from reductions in length of stay and delayed discharges. The programme mitigates this by focusing on whole ward and service redesign, rather than incremental bed reductions, ensuring that savings are realised at scale and aligned to service change. 8.3 System and Interdependencies and Cultural Change The success of the programme is dependent on strong alignment between acute services and HSCPs. There is a risk that improvements in one part of the system are not matched by capacity or change in another, resulting in continued bottlenecks. This is mitigated through the adoption of a whole-system transformation approach, with shared objectives, joint accountability, and integrated performance monitoring. Cultural change is also a key risk, particularly the need to shift from hospital-based assessment to a Home First model. The programme addresses this through clinical leadership, ongoing engagement, and embedding Discharge Without Delay principles into routine practice, including MDT board rounds, LOS reviews and discharge planning processes. Sustained improvement will depend on consistent application of these principles across all teams.
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Page 21 of 24 9. Governance, Oversight and Assurance Robust governance and oversight arrangements are in place to ensure that risks are actively managed and mitigations delivered. As set out within the business case, oversight will be provided through: • Ayrshire Transformation Group – providing strategic leadership and oversight of delivery, including financial alignment and system-wide risk • Flow Assurance Board – providing monthly executive level oversight of delivery, performance and resource transfer. • DWD Programme Board – providing monthly operational oversight of patient flow, discharge performance and escalation of risks • Defined workstreams – responsible for delivery of key enablers and monitoring of associated risks These structures are supported by routine performance reporting, including indicators such as length of stay, delayed discharges, discharge rates and occupancy. This ensures real- time visibility of system performance, early identification of emerging risks, and the ability to take corrective action where required. Overall, the programme is designed as a controlled and phased transformation, with clear dependencies, defined enablers and strong governance. Risks are fully aligned to the case for change and delivery model set out in the business case, and mitigating actions are embedded within programme delivery. The combination of: • phased implementation • conditional financial transfer • investment in community capacity • and robust governance and oversight provides a high level of assurance that risks can be effectively managed, and that the programme can be delivered safely while improving patient outcomes, system performance and long-term financial sustainability. In addition to the above it is proposed that each organisation via their structures will be accountable for the delivery of their element and trajectories identified in the programme. This will include a performance objective for the responsible Director and through the line. Full details outlining roles and responsibilities is set out within Appendix 4.
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Page 22 of 24 10.0 Conclusion NHS Ayrshire and Arran continues to experience sustained and escalating system pressure, with overcrowding across both emergency departments and inpatient wards now a persistent feature of daily operations. This is resulting in an increasing number of patients being cared for in non-standard care environments, including corridor spaces and surge areas, which fundamentally compromises privacy, dignity and the ability to deliver safe, person-centred care. Patients who remain in these environments, or who experience prolonged stays in hospital due to delayed discharge, are exposed to avoidable harm, including deconditioning, increased risk of falls, infection, and loss of independence. These impacts are most acutely felt by older people and those with complex needs, who represent a significant proportion of the current inpatient population. The current model is therefore not only operationally unsustainable, but also clinically and ethically unsatisfactory. The position is further compounded by the number of individuals who remain in hospital for extended periods despite being clinically ready for discharge. For these patients, hospital is no longer the most appropriate setting for care. This raises important considerations in relation to: • safeguarding individual rights and wellbeing • avoiding unnecessary institutionalisation • ensuring timely access to appropriate care and support in the community • supporting people to live as independently as possible, in line with a Home First approach Extended delays in discharge represent a system failure to meet these responsibilities, with individuals experiencing prolonged hospital stays due to capacity and process constraints rather than clinical need. This underlines the urgency of shifting to a model that enables timely, safe and person-centred transitions of care. Phase 1 of the Unscheduled Care Programme has provided important insight and has enabled progress in targeted areas; however, the non-recurring nature of the funding has limited the scale, pace and sustainability of improvement. As a result, the programme has not yet delivered the system-level change required to reduce length of stay, eliminate delays, or relieve pressure on acute services. Approval of a combined Phase 1 and Phase 2 approach is therefore essential. This will: • secure the recurring investment required to sustain and stabilise Phase 1 • enable rapid progression to Phase 2, delivering transformation at the scale required • support immediate mobilisation to meet the September and December 2026 trajectories • establish a whole-system Transfer of Care model, aligned to Discharge Without Delay and Home First principles
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Page 23 of 24 Central to this transformation is the planned and phased reduction of acute bed capacity, including ward closures, enabled by: • demonstrable improvements in flow and discharge performance • expansion of community and intermediate care capacity • strengthened partnership working across Acute Services and HSCPs This will be accompanied by a phased transfer of resources from acute services to HSCPs, ensuring that investment follows the patient and supports the shift in the balance of care. This approach will enable the system to move from a position of reactive, high- cost acute provision to a more sustainable, preventative and community-focused model. While this business case focuses on Phases 1 and 2, it is recognised that further transformation will be required to deliver full system sustainability. This will be progressed through Phase 3 of the programme, which will set out the longer-term investment and service redesign required across the wider system. Critically, this programme is not solely about performance improvement or financial sustainability. It is about restoring the quality, safety and dignity of care for patients, ensuring that: • patients are treated in appropriate care environments • unnecessary hospital stays are avoided • discharge is timely, planned and supported • care is delivered as close to home as possible Without approval and immediate mobilisation, the organisation will be unable to deliver the required trajectories, and the risks associated with overcrowding, delayed discharge and poor patient experience will continue to escalate. This business case therefore sets out a clear, phased and deliverable plan to address current system pressures, improve outcomes and experiences for patients and staff, and establish a sustainable whole-system model of care for the future 11. Recommendation It is recommended that the Board: 1. Approve the full programme of investment and delivery across Phase 1 and Phase 2 of the Unscheduled Care Programme, recognising that: • Phase 1 requires confirmation and approval of recurring funding to sustain and stabilise existing improvements • Phase 2 requires approval to proceed at pace and scale to deliver the planned whole-system transformation and associated performance trajectories
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Page 24 of 24 2. Approve the transition to a whole-system Transfer of Care model, enabling delivery of a Home First approach through: • Expansion of community-based capacity • Embedding Discharge to Assess (D2A) and Discharge Without Delay (DWD) principles • Strengthened integration between Acute Services and HSCPs. • The planned and controlled reduction in acute bed capacity, including ward closures • Demonstrable establishment of sustainable community capacity 3. Note that delivery of the September and December 2026 performance trajectories is contingent upon immediate approval and mobilisation, including: • Implementation commencing from early July 2026 • Timely recruitment and service mobilisation across Phase 1 and Phase 2 • Coordinated system-wide execution 4. Support the governance and assurance arrangements outlined within the business case, including oversight of: • Phased delivery and associated risks • Financial performance and resource transfer • Achievement of agreed outcomes and benefit