The implementation of proportionate care (or Optimal Handling Care) at University Hospital Southampton

A growing demand on care resources across the health and social care continue to challenge the system. This is leading to missed operational standards, including delayed hospital discharges and potential risks to patient safety. In particular, the availability of community care hours is a key factor in acute hospital delays. 

Proportionate Care refers to the moving and handling support that is required during care, whether in a hospital environment, residential care setting or the person’s home. Historically, moving and handling care plans have often over-prescribed care, with the ‘right-sizing’ of care plans often undertaken by social care later in the patient community care pathway. Proportionate Care is an approach that aims to prevent 'over-prescribing' of care by promoting a collaborative culture of managed risk-taking. This involves staff, patients, and families working together to maximise patient independence and overall care quality. The results include enhanced patient outcomes, reduced staffing needs for effective moving and handling, and fewer non-medical delays in discharge.

Unnecessary and prolonged hospital stays may have harmful consequences, especially for older people. These consequences include a higher risk of inpatient falls, hospital acquired pressure sores and sleep deprivation. In turn these may lead to a decline in both mental and physical health. 

Following an initial investment in a Community Upskilling Programme by NHS Hampshire and Isle of Wight Integrated Care Board (ICB), an opportunity arose to pilot the implementation of Proportionate Care at UHS. Significant benefits for patients were anticipated by the Trust, alongside the expected reduction in discharge delays and the release of community care hours. The pilot would also serve as an integral part of the Home First agenda and the Trust’s objective to decrease the number of delayed National Pathway 0 discharges.

Two scoping pilots were conducted during 2022 (in March and August) to review the impact of implementing Proportionate Care in the acute hospital setting (UHS). The pilots were conducted by two senior Occupational Therapists, identifying the number of patients appropriate for Proportionate Care across the hospital. The pilots ran across a six-week period, two weeks in March 2022 and four weeks in August 2022 (excluding weekends). The first pilot was centred on patients in the Medicine of Older People units, Medical Wards, and Acute Medical Unit. The second pilot was opened to all inpatient wards. The findings demonstrated a bed day saving ranging from 4.7 to 18.9 per patient. These are bed day savings calculated from the date that patients are deemed to be medically optimised for discharge. 

Across the two pilots that were undertaken, 67 patients were identified as awaiting double-handed care packages (requiring more than one carer). Based on the pilot data, an average of 67 patients were assessed over a six-week period. This established the weekly activity volume for potential Proportionate Care assessments at 11.1 patients per week (c.577 for the year). Crucially, the pilots also demonstrated that patients returning via the National Pathway 0 saw a reduced hospital length of stay and improved patient outcomes.

Following the pilot’s success, UHS Trust Board was assured by the local County Council’s continued support for Proportionate Care in the community. This commitment had already been demonstrated by a hosted engagement event with local care providers. A local delivery system steering group, which included community and social care colleagues, was established. This group contributed significantly to the pilot's success by establishing a Proportionate Care discharge pathway with timely reviews, thereby fostering a positive risk-taking culture within the acute setting and reducing the risk of overprescribing care due to a collaborative pathway approach.

Existing therapy staff were involved in the pilots. The pilots were constrained by the staffing; because staff were continuing to pursue their existing roles in the Emergency Department and the Medical Wards. Therefore, it wasn’t possible for those involved to see and assess all possible eligible patients.

In 2023, a business case was submitted for a small Proportionate Care workforce to undertake a detailed one-year study of the implementation of Proportionate Care:

• One-year Fixed Term FTE Band 8a Occupational Therapist (OT)
• One-year Fixed Term FTE Band 4 Therapy Technician

The business case investment was to ensure the time, resources and capacity for the specialised clinicians to seek patients appropriate for Proportionate Care to manage and contribute to the interventions, to collect data, and to engage with community partners.

In 2023, there was a limited evidence base for Proportionate Care in the acute hospital setting. Previous research has been isolated to the local authority settings. Barriers to implementing Proportionate Care have included risk assessment responsibilities, staff moving and handling confidence and adjusting the culture of not overprescribing care.

Implementing Proportionate Care was, as clearly stated within the business case, aimed at building the evidence base required for evidence-based change (making Proportionate Care ‘standard practice’).

The 12-month Proportionate Care Project launched on 2 October 2023 funded by the hospital flow programme.

Investing in leadership and dedicated resources was necessary to achieve the expected core benefits, including better collaboration with community partners.

The anticipated benefits of the Proportionate Care Project (as outlined in original business case April 2023):

• increased patient satisfaction: ensuring individualised care, improving availability of care and patient choice in discharge destination (this includes choice of location for end-of-life care)
• to release c.1558 inpatient bed days for the year back into operational capacity, allowing admission of those patients who require acute care (based on the data from the scoping pilots)
• to reduce the risk of over prescription of community care resources
• support hospital flow through accurate identification of care needs for discharge, increasing joint working with discharge team to complete timely care referrals
• increase availability of acute hospital beds, assist in meeting the Emergency Department 4-hour operational target
• opportunity to be involved in emerging research and developing an evidence base for proportionate care
• improved communication and collaboration with community partners, improved cross organisation working to support hospital discharges and reduce 30-day hospital readmissions.

In the first 12 months, 651 patients were assessed. The sole criterion for these patients was the identification of a new need for either care or moving and handling support. Of the 651 patients, 52 per cent saw a reduction in their care needs, which resulted in a release of 3,039 bed days in 12 months.

The 12-month Proportionate Care outcome data served as the catalyst for system-wide implementation, marking the start of adoption at scale across the Hampshire and Isle of Wight system.

By October 2024, as part of the Trust Investment Group review of the initial investment, substantive funding was agreed to continue the Proportionate Care service. This included additional staffing investment.

Data from the first year of operations highlighted additional opportunity if there was increased staffing :

• increase the success rate of Proportionate Care through earlier identification of patients who may be suitable
• increased education and training resources to promote Proportionate Care across inpatient wards. This will support a business-as-usual model and reduce the risk of deconditioning
• ensuring ongoing leadership and oversight of the delivery of Proportionate Care through a strength-based approach to delivery of ward care
• increase the number of Pathway 0 discharges
• increase in Pathway 1a (reablement discharge pathway) which will contribute to further length of stay reduction
• increase in length of stay saving, predicting to save 4,740 bed days with the additional staffing investment
• robust documentation of moving and handling plans, improved handover to community partners
• increased availability of onsite demonstration training for family/informal carers, thus increasing Pathway 0 discharges
• provision of data, contributing to the evidence base and research. This will ensure the long-term sustainability of the approach.

Since the service commenced in October 2023, process and outcome data have been collected to demonstrate the impact of the proportionate care investment.

• patients referred in first 12 months (Oct 2023 – Sept 2024): 651
• patients reviewed with the additional staffing (Band 6 0.8 Whole Time Equivalent) (Oct 2024 – Apr 2025, 26 weeks): 322
• weekly referrals: Stable
• success rate improvement with additional resources: 52 per cent → 63 per cent
• bed days released over 18 months: 4,789.

Impact on Pathways and Safety:

• increase in Pathway 0 discharges: additional 87 patients
• Pathway 0 increased by 6 per cent (Oct 2024 – Apr 2025 vs first year)
• reduction in pressure sores by 1.3 per cent
• reduction in falls by 5.9 per cent
• improved discharge communication with comprehensive moving and handling plans.

Readmissions:

• there was an overall 6 per cent reduction in Pathway 1 readmissions compared to 2022-2023 baseline
• patients maintained or improved functional outcomes according to Clinical Frailty Scale, Therapy Outcome Measures (scale 36), and patient preference recording.

Despite the outcome results, embedding Proportionate Care as a standard practice has been difficult in and with community care providers, examples of which have been

• limited staff confidence
• inconsistent engagement from external care agencies
• insufficient access to necessary equipment.

To address the barriers and upskill the workforce, the NHS Hampshire and Isle of Wight Integrated Care Board invested in an Upskilling Programme, including a system-wide Clinical Leadership secondment, led by the Chief Allied Health

Professional. The programme commenced in Autumn 2024.

The programme was commissioned to ensure the effective delivery of Proportionate Care across the system, acknowledging the importance of investing in an upskilling programme. In February 2025, the co-designed (health and social care)

Proportionate Care upskilling programme was launched across Hampshire and Isle of Wight. The programme included the development of comprehensive suite of digital film resources, designed to complement care plans and support carers in the client-specific, targeted techniques.

By July 2025, over 150 Proportionate Care ‘Prescribers’ had been trained across all four local delivery services.

Core Key Performance Indicators were agreed; today, ‘prescribers’ continue to complete monthly data collection reports. A system-wide target was set of 174 assessments per month across the HIOW acute and community services. Data from

UHS suggests that 50 per cent of those assessed will be suitable for Proportionate Care.

During the first three months of collecting system data, more than 690 patients have been assessed for Proportionate Care. Performance metrics are trending positively, with 50 per cent of all assessments consistently deemed appropriate for

Proportionate Care. Furthermore, the rate of patients achieving an overall reduction in their care pathway has risen to 44 per cent from 38 per cent.

Future analysis will focus on tracking how many community care packages are sustained or reduced 12 months post-discharge.

At University Hospital Southampton, the future focus is on integrating Proportionate Care into the fundamentals of care programme, driven by continuous multidisciplinary team collaboration. The rollout of ward pilots is currently upskilling nursing and healthcare staff in Proportionate Care techniques. The programme of work directly targets the prevention of deconditioning, thereby reducing patient dependency for equipment and complex discharge care packages. The results of the pilot work are being shared with Hampshire and Isle of Wight to support ward embedding and scalability.

There is a recognised need for a co-production approach in the delivery of Proportionate Care to ensure sustainability. This has been reflected in the health and social care sectors' co-design of the NHS Hampshire and Isle of Wight Proportionate Care upskilling programme. 

The significant executive-level support and resource investment from University Hospital Southampton (UHS) and the Hampshire and Isle of Wight Integrated Care Board (ICB) have been crucial to the success of the Proportionate Care initiative.

To scale the Proportionate Care work and ensure its long-term sustainability, the following are being implemented.

• Resource accessibility: A resource bank has been developed to make all Proportionate Care upskilling training materials easily accessible across the system.
• Data and measurement: Business Intelligence (BI) reporting is being used to collate essential data and establish platforms for recording agreed outcome measures. The Therapy Outcome Measure (TOM) is serving as the system's designated outcome measure.
• Evidence and practice integration: Opportunities, including applying for small grants, are being explored to publish the work, thereby growing the evidence base and encouraging its adoption as "business as usual" in ward settings.
• System-wide engagement and future vision: NHS Hampshire and Isle of Wight Integrated Care Board has funded a system-wide Continuing Professional Development (CPD) conference. This event will be used to celebrate the success of Proportionate Care implementation and explore future opportunities that align with the NHS 10-year plan and its three strategic shifts.