North Cumbria Goes Live with Strata Health Digital Care Pathways

North Cumbria goes live with a fully integrated model for digitising intermediate care pathways, co-produced with system partners and powered by Strata Health.

North Cumbria Integrated Care NHS Foundation Trust has gone live with Phase 1 of a system-wide transformation programme focused on digitising intermediate care pathways across health and social care.  

This builds on an already established Transfer of Care Hub and moves beyond coordination into full system alignment. It directly supports the national direction set out through neighbourhood health, hospital to home models, and the wider 10 year vision for health and social care. 

For the first time, all intermediate care services across the system are connected through a single, live digital model that supports the patient journey from initial referral through to independence or long-term care provision. 

This is not simply digitising existing processes. It is a redesign of how the system operates. 

What has been implemented? 

A single, standardised referral system is now in place across all Discharge to Assess pathways. Every patient referred into intermediate care enters one shared digital pathway that remains live throughout their journey. 

The model spans Pathway 0 through to Pathway 3 and replaces multiple referral routes and disconnected processes with one continuous, system-wide approach.  

Digitising intermediate care pathways in this way means: 

• one referral route across all services
• one shared dataset used by health and social care
• one live view of patients, demand, and capacity 

Patients are no longer passed between services through separate processes. The pathway remains live from entry through to outcome. 

What makes this different? 

This programme brings together three elements that are often delivered in isolation, but rarely as one: 

• full alignment of intermediate care pathways across NHS and local authority partners
• a single live referral and tracking system
• real-time data and performance visibility embedded into daily operational practice 

The result is a fully digitalised intermediate care model that supports how systems are expected to operate going forward. 

It enables: 

• real-time tracking of patients from referral through to outcome
• live visibility of demand and capacity across all services
• active flow management rather than retrospective reporting
• consistent capture of delays, utilisation, and outcomes
• system-wide performance monitoring and trend analysis 

This is not a reporting tool. It is a live operational system used to manage flow as it happens. 

From fragmented services to a single system 

Intermediate care has traditionally operated as a collection of separate services, each with different processes, data, and levels of visibility. This fragmentation is a recognised challenge nationally. 

Digitising intermediate care pathways has removed that fragmentation in North Cumbria. 

All partners now work from the same information, in real time, enabling decisions to be made from a whole-system perspective rather than individual service pressures. 

This directly supports national ambitions to integrate health and social care delivery, reduce duplication, and improve how systems manage flow. 

Operational impact 

Since going live in November 2025, teams are already seeing a shift in how flow is managed.  

Early benefits include: 

• clear visibility of where every patient is within the pathway
• earlier identification of delays across organisations
• reduced duplication in referral and assessment processes
• more consistent, system-wide decision making
• the ability to actively manage capacity in real time 

This is supporting a move away from reactive discharge management towards proactive, system-led flow that keeps people closer to home wherever possible. 

A platform for system performance 

Digitising intermediate care pathways has also enabled real-time dashboards that link operational delivery directly to system performance. 

This includes: 

• live pathway status across all services
• demand versus capacity views
• performance against key metrics
• trend data to support planning and commissioning
• outcome tracking across the full patient journey 

This creates a single version of the truth for both frontline teams and system leaders, aligning with national expectations around transparency, outcomes, and data-driven decision making. 

Delivering neighbourhood health and hospital to home 

This programme provides a practical example of how national policy can be delivered on the ground. 

By digitising intermediate care pathways, North Cumbria has created a model where: 

• patients move through services without repeated referrals or handoffs
• care is coordinated across organisational boundaries
•  decisions are made using real-time system insight
• outcomes are tracked across the full pathway 

This moves beyond ambition and demonstrates what integrated, neighbourhood-based care looks like in practice. 

A model for wider adoption 

The approach aligns with priorities across NHSE, local government, and partner organisations such as LGA and GIRFT, particularly in improving flow, strengthening discharge to assess, and making best use of intermediate care capacity. 

It provides a scalable model for systems looking to move from aspiration to delivery by combining pathway alignment, operational redesign, and digital infrastructure into one approach. 

“This work has allowed us to move beyond coordinating discharge to actively managing flow as a whole system. It aligns with national direction around neighbourhood health and hospital to home, but more importantly, it shows how that can be delivered in practice. We now have a live, shared view of patients, capacity, and performance across all intermediate care pathways, which is fundamentally changing how we operate and improve outcomes.” 

Paul Carruthers, Transfer of Care System Leader – North Cumbria

Looking ahead 

Phase 2 will build on this foundation, expanding coverage, enhancing analytics, and further embedding the model across partners. 

This is not simply a digital solution. It is a fully aligned, system-wide approach to delivering intermediate care in line with the future direction of health and social care. 

Strata Health is proud to partner with North Cumbria in building a system-wide model for discharge and transfer of care.