East Lothian Health and Social Care Partnership (ELH&SCP) has launched an innovative project to reduce pressures on hospital care this winter and help streamline the discharge process for patients.

A team of Allied Health Professionals (AHPs), ‘the In-Reach Team’, has been posted into the Royal Infirmary of Edinburgh (ERI) to support the triage and assessment of patients from East Lothian as they arrive.

By restructuring the process on arrival at the hospital, they will be able to help patients return home as soon as they are medically well and prevent patients’ discharge from becoming delayed.

They will be able to support patients during the preparations for returning home and ensure they have access to ongoing community-based care and treatment.

In turn, the project will free up more hospital beds for those who urgently need hospital care, just as the NHS moves into one of its toughest periods of the year.

Statistics show that East Lothian has among the smallest numbers in Scotland of patients whose discharge has been delayed.

The new project is part of a targeted pan-Lothian effort to improve the discharge process and make sure more patients can return home to their communities as soon as possible.

Lesley Berry, Chief AHP and General Manager for East Lothian’s Rehabilitation Service, said: “This initiative is focused on using local knowledge to support local people. “By supporting the existing teams in the Royal Infirmary of Edinburgh with specialist East Lothian experience, we can significantly support patients to get the right level and service of care to meet their individual requirements closer to home.”

The East Lothian AHP team is made up of a Clinical Lead Occupational Therapist, a Clinical Lead Physiotherapist, a Team Lead Occupational Therapist, a Physiotherapist, an Occupational Therapist, a Band 4 Assistant Practitioner with knowledge of home technology systems, and strong links with the Adult Social Work Services Team.

As soon as an East Lothian patient arrives in hospital, the Physiotherapy and Occupational Therapy teams work assess the patient’s condition to identify the most appropriate treatment and care support needs.   The In Reach Team, working alongside the wider multi-disciplinary East Lothian Health and Social Care Partnership team, collectively focus on getting the person to the right place.   Understanding that a hospital bed is often not the best solution, wherever possible the team’s priority is providing a “home first” option.

By understanding the pathways and support systems available within East Lothian, the AHPs are able to use their extensive knowledge to make patient assessments and referrals into local community-based resources, allowing patients to return home as soon as possible, and in some cases prevent hospital admissions in the first place.   

If a patient is already engaged with care services when they present at hospital, the In Reach Team are able to provide local knowledge support to ERI colleagues; accessing existing care profiles, providing advice and recommendations about community options which might be suitable, such as outreach, day centre facilities and voluntary networks.  

By linking with the community adaptation team, the AHPs can also find innovative solutions to install equipment or technology-based care solutions to support people to live independently in their own home.

Jill Gillies, Director of Unscheduled Care, NHS Lothian, said: “We’re delighted to have the East Lothian AHP Team on board to support the team at the Royal Infirmary of Edinburgh.  “Our services and teams are under significant and ongoing pressures because of an overall increase in use of our health services.   We need to make sure that we have the hospital beds and staff available to provide treatment to those who urgently need it.  

“That is why, across Lothian, we are working with Health and Social Care Partnerships, community services and third sector organisations to ensure patients can safely return home, or to their homely setting as soon as they are clinically ready.  This ensures we have beds available to provide care and treatment for the residents of Lothian. 

“This innovative project aims to help to streamline the admission and discharge process for patients in East Lothian and in some cases even prevent hospital admissions.”


Further Information
For advice and tools to manage your health and wellbeing, and resources to assist you care for others, visit East Lothian Rehabilitation Service's website:  abetterlife.eastlothian.gov.uk 

Published: Monday, 14th November 2022