Coming Home from Hospital This Winter: What Families Need to Know

Coming out of hospital should feel like the good bit. For a lot of families it is the part that goes wrong, because the ward is under pressure, the discharge happens faster than anyone expected, and nobody has worked out who is making the tea on the first night back. This is a practical guide for anyone in Stoke-on-Trent or Staffordshire whose parent or relative is in hospital now, or might be this winter.

What is Discharge to Assess?

Discharge to Assess is the NHS model where someone leaves hospital as soon as they are medically fit, and their longer term care needs are then assessed at home rather than on a ward. The thinking behind it is sound. Hospitals are not restful places, people lose strength and confidence quickly on a ward, and most of us recover better in our own bed. It was set out in NHS England’s hospital discharge and community support guidance in January 2024, and it is now the normal route out of hospital for most older patients.

What it means in practice is that the assessment you might expect to happen before discharge often happens afterwards, at home, in the first few days. That catches families out.

What are the four discharge pathways?

• Pathway 0. Home with no new support. Most people.
• Pathway 1. Home with support, which usually means carers visiting, equipment delivered, or therapy at home.
• Pathway 2. A short stay in a bed somewhere else, for rehabilitation or recovery, before going home.
• Pathway 3. A longer term placement where going home is not realistic.

Ask which pathway your relative is on. It is the single most useful question you can ask on the ward, because it tells you what is actually being arranged and what you will need to sort out yourself.

Who pays for care after hospital?

For a short period after discharge, support arranged through the NHS pathway is usually funded rather than means tested. How long varies, commonly up to four weeks and sometimes longer depending on the pathway and the local arrangement, so ask the discharge team exactly how long has been agreed and get it in writing. After that period, ongoing care is normally assessed and charged under the Care Act 2014, unless the person qualifies for NHS Continuing Healthcare.

The gap at the end of that funded period is where families most often get caught out. If the funded weeks end in the middle of December and nobody has arranged what comes next, that is a difficult conversation to have at short notice. Ask early what the plan is for week five.

What should I ask before my relative leaves hospital?

• Which pathway are they on, and what exactly has been arranged?
• Who is coming, how often, and what will they actually do?
• How long is this funded for, and what happens when it ends?
• What equipment is being delivered, and when? Will it arrive before they do?
• What has changed in their medication, and can we have it in writing?
• Is a Continuing Healthcare assessment being done?
• Who do we ring in the first week if something is not right?

Write the answers down. Ward staff are stretched and things get passed on verbally, so a written list of what was agreed is worth a great deal if something is missed.

Can we say no if it does not feel safe?

You can raise concerns, and you should. If the house is cold, there is no food in, the stairs are not manageable or nobody will be there that first night, say so clearly to the ward and ask for it to be recorded. A care needs assessment should be offered to anyone who appears to need ongoing support. You cannot keep a bed indefinitely, and it is fair to say that hospitals need beds this winter, but a discharge that falls apart in 48 hours helps nobody and often ends in readmission.

If you want the detail on your rights, Carers UK has a good plain English guide to coming out of hospital.

Why this winter in particular?

Because the pressure is already being talked about openly. On 18 October the government announced nearly £140 million for urgent care schemes ahead of winter, with the Health Secretary saying plainly that this winter will be more challenging than usual. A&E doctors have said much the same.

What that means for families is simple enough. Beds will be needed, discharges will be brisk, and the people who do best are the ones whose family has asked the questions above early rather than on the afternoon it happens.

Where we come in

A lot of what we do over winter is exactly this. Picking someone up from a discharge that happened quickly, getting the house warm, making sure the medication is right, and being there for the first week while everyone finds their feet. Sometimes that is a few weeks of support and then people manage perfectly well on their own. Sometimes it turns into something longer. We will tell you honestly which one we think it is.

If your relative is in hospital now and you want to talk it through before they come home, call us on 01782 528087 during office hours, or our 24-hour line on 07944 200990 if it is already happening and you need someone quickly. You can also read more about short notice and emergency care, or ask your local council’s adult social care team at Staffordshire County Council or Stoke-on-Trent City Council.