Hospital Discharge and Care Planning

Hospital discharge planning should begin from the moment you are admitted. A multidisciplinary team — including doctors, nurses, occupational therapists, physiotherapists, and social workers — is involved in assessing your readiness for discharge and your post-discharge care needs.

The hospital should provide you with a written discharge plan explaining what care has been arranged, any medications you have been prescribed, follow-up appointments, and who to contact if problems arise. You (and your family or carer, with your consent) should be involved in discharge planning discussions.

Under the Health and Social Care Act 2022, NHS bodies and local authorities have duties to cooperate in facilitating timely and safe hospital discharges. The Discharge to Assess (D2A) model, introduced to relieve pressure on hospital beds, means that formal care needs assessments increasingly take place at home or in a step-down intermediate care facility rather than in hospital before discharge. This is lawful, but must be properly managed.

You have important rights in relation to hospital discharge:

• Right to be involved in discharge planning — You should be consulted about when you will be discharged and what support will be in place;
• Right to refuse discharge — If you do not feel safe to be discharged, you can refuse. The hospital cannot physically force you to leave. However, the hospital can continue to assess whether admission is clinically necessary — if it is not, there may be pressure to leave and the hospital is not obliged to continue occupying a bed you do not clinically need;
• Right to a care needs assessment — If you appear to need ongoing care and support after discharge, you are entitled to a care needs assessment from the local council. This can be done in hospital or at home after discharge;
• Right to discharge to your preferred setting — You should generally be discharged to your own home if appropriate support can be put in place, not placed in a care home simply because it is more convenient for the hospital.

If you or a family member is discharged without appropriate care in place, readmission becomes more likely and harm can result. Steps to take if you believe discharge was unsafe:

• Raise concerns immediately with the ward staff, the ward manager, or the PALS (Patient Advice and Liaison Service) team at the hospital;
• Contact the local council to request an emergency care needs assessment if support is not in place;
• Make a formal complaint to the hospital's Patient Experience team if the concerns are not addressed;
• Report to the CQC if you believe there was a systematic failure;
• Complain to the Parliamentary and Health Service Ombudsman (PHSO) if the hospital's complaints process does not resolve the matter.

Hospital discharge is one of the most common points at which NHS Continuing Healthcare (CHC) eligibility should be considered. When someone has been admitted to hospital with complex health needs, and those needs are likely to require ongoing care after discharge, a CHC screening checklist should be completed before they leave hospital. If the checklist indicates that a full CHC assessment is needed, the Integrated Care Board is responsible for arranging it — and for arranging or continuing to fund care during the assessment period.

In practice, CHC is frequently not considered at discharge. Families are sometimes asked to fund care home placements or complex home care packages privately, without having been offered a CHC assessment. If a family member has complex health needs and is being discharged to a care home or with a substantial home care package, ask the ward team or the hospital social worker explicitly: "Has a CHC checklist been completed?" If not, request one before discharge.

If a CHC checklist is completed at discharge and concludes that the standard threshold has not been met but the person is deteriorating rapidly towards end of life, ask about the CHC Fast Track pathway. A clinician can trigger Fast Track — which must result in fully funded care being arranged within 48 hours — if the person has a rapidly deteriorating condition that may be entering a terminal phase. This is a powerful mechanism that families should be aware of and should not hesitate to request at the discharge planning stage.

Where there is a dispute at discharge about whether care should be funded by the NHS (CHC), the council, or the family, the responsible bodies must continue to provide care during the dispute. Care must not be withdrawn while a funding dispute is being resolved. If you are being asked to fund care that should be NHS-funded, contact the ICB's CHC team directly and seek independent advice.