Spotlight on: Falkirk’s Winter Pressures Project

A new report published by the National Development Team for Inclusion (NDTi) and Healthcare Improvement Scotland’s iHub has recognised the positive work led by Falkirk Health and Social Care Partnership to improve the flow of patients through Forth Valley Royal Hospital.

Think home, think community – addressing the challenges in unscheduled care

Working together with five local voluntary organisations, Falkirk Health and Social Care Partnership set out to enable people admitted to hospital to return home in a timely and safe manner.

Supported by Winter Pressures funding from the Scottish Government, people have been supported by appropriate community resources and introduced to longer-term community networks to help improve overall wellbeing and reduce pressure on acute services.

The project provided a range of immediate and ongoing support options:


  • Transport home
  • Delivery of medication
  • Food packs
  • Wellbeing visits


  • Support for carers
  • Grocery support
  • Support with household tasks
  • Befriending
  • Social networks
Working together – who is involved?

Falkirk Health and Social Care Partnership, Clackmannanshire and Stirling HSCP, the Royal Voluntary Service, Strathcarron Hospice, Falkirk and Clackmannanshire Carers Centre, Dial- A-Journey, and Food Train have worked together to provide a range of support to return people home as soon as possible.

By addressing immediate needs, and following up with a ‘good conversation’ to consider any longer-term needs, the project set out to achieve:

  • Reduced delays in discharge from hospital and re-admissions to hospital (for non-clinical reasons)
  • Avoid admission to hospital by providing alternative community support
  • Reduction in the social work assessment pending listed
  • Increase access to support
  • Increased support for carers and families
Role of Link Workers

Key to the project is the role of the link workers, who are employed by the Royal Voluntary Service and work directly with teams across the hospital, including front door and discharge teams.

The link worker arranges and co-ordinates support from third sector partners to enable people to return home safely. The link worker then conducts a follow up visit and holds a “good conversation” with the individual themselves (including their carer if involved), and using an asset-based approach agrees with the individual what would help to support both to continue to maintain the individual at home as well as to maintain their independence and wellbeing. This includes consideration of local community resources and links.

Role of Partners
  • Dial-A Journey provide transport from hospital home but also are available to collect medication and equipment, which has reduced delays in hospital for people simply awaiting for prescriptions to be made up.
  • Royal Voluntary Service provide a range of support at home including home checks, practical support and links into community activities.
  • Strathcarron Hospice, as part of their Compassionate Communities approach, provide access to social networks and befriending.
  • Food Train make up food packs a number of which are stored in the hospital for ready access and also provide follow up support with grocery shopping and support with household tasks.
Demonstrating success
  • The number of people using the service has exceeded expectation with over 880 referrals since it started in December 2021 (as at end of April 2022).
  • The project has been successful in preventing delays in hospital and enabling to people to get home safely – a key outcome for patients. Our immediate support enabled people to leave hospital within 1-hour of referral to Dial-a-Journey.
  • This is a great example of partnership working demonstrating innovation and effective collaboration and highlights the importance of linking effectively into community supports.
Ongoing support – case study

The Link Worker made a follow up call to Mark* a few weeks after discharge. Things were going reasonably well, but he admitted he was really missing his fishing.

Last year his wife would take him in their own car to a loch where they have accessible fishing boats, but following discharge his wife had become too frail to lift his wheelchair into the car. This meant he didn’t get fishing, and she didn’t get a break.

The Link Worker connected them to Dial-a-Journey who now take him to the loch every week. With their support, he is now able to connect with friends and enjoy an outdoor activity while his wife also meets up with friends for a chat and informal support.

(Names have been removed/altered within this case study)

There’s an app for that – use of technology

The Partnership played an enabling role by developing a bespoke app to help the Link Workers collect the required information, record relevant data sharing consent from the patient, share information with partners and process any personal data in accordance with the Data Protection Act.

Next steps

The aim is to build on the successes, introducing more services and new access points, while also extending the project to cover the full year (not just the traditionally busy winter period).

Further info

This case study is part of two reports from NDTi, funded by Healthcare Improvement Scotland’s iHub, which explore the positive impact of community led support initiatives across the UK.

You can find out more information on the NDTi website.