Hospital discharge for older people

The Context

IMPACT Network

Networks are meeting across the UK, coordinated by 

  • In Scotland, there are two networks. One is coordinated by Y.O.U. (Your Options Understood) and includes representatives from carers organisations, individuals with lived experience, a local authority representative, a support provider, and a government-funded organisation. The other network, coordinated by Anuj Dawar in Grampian, involves a Strategic Lead responsible for Delayed Transfers of Care, a carer, service providers, leads from elderly and veteran charities, and an Occupational Therapy Lead from ARI Hospital.
  • In Wales, the Network coordinated by Hywel Dda UHB West Wales in Pembrokeshire includes various stakeholders such as a Partnership Manager and Team Support from the Regional Innovation Coordination (RIC) Hub, personnel from Organisational Development and primary community care, representatives from Solva Care, members of the Intermediate Care Team, and Clinical Lead Nurses and First Contact Team from Pembrokeshire County Council.

Discussion Materials

Before the first Network meeting, IMPACT carried out an evidence review of research, lived experience and practice knowledge.

This evidence review was used as ‘discussion material’ in the Networks, designed to spark conversation and ideas. It’s a helpful way to surface more evidence, with people in the Networks sharing their own practice knowledge and lived experience.

A summary of findings and links to the discussion materials follow:

Why is this an important issue?

  • Delayed discharges from hospitals strain healthcare systems. However, premature discharge can pose life-threatening consequences.
  • They impact the well-being and quality of life of older individuals and their families.
  • They can increase the risk of infections and reduce independence, leading to further complications.
  • They exacerbate existing challenges within health and social care systems, such as communication breakdowns and inadequate support.
  • Addressing this issue is important to improve healthcare resources and ensuring access to hospital care for those in need.
  • Respecting the experiences and needs of older individuals in hospital discharge processes reflects a commitment to person-centred care and dignity in ageing.


  • Delayed discharge: Older people sometimes face delays in leaving hospitals due to a lack of support at home, leading to prolonged stays even when they are ready for discharge.
  • Fragmented health and social care systems: There are problems with coordination and communication between health and social care teams, leading to difficulties in providing adequate support.
  • Negative language and blame: The use of stigmatising language like “bed blocking” can lead to blame being placed on older people, rather than addressing systemic, structural issues.
  • Impact on health services: Delayed transfers of care contributes to pressure on healthcare resources, including hospital bed availability and staff frustrations.
  • Impact on both older people and their families: Prolonged hospital stays can have significant negative effects on patients’ physical and mental well-being, as well as their independence and quality of life. Families may feel overwhelmed and unsupported.
  • Premature discharge: Pressures on hospitals sometimes lead to premature discharge, which can be life threatening; risking patients’ well-being and potentially resulting in readmissions.
  • Lack of comprehensive research: While there is some research on the issue it tends to focus on prevalence and not the reasons behind the issue and therefore, there’s a lack of involvement of older people, families, and frontline social care staff in finding solutions.

Potential solutions

Patient centred care: Prioritise what matters to older people and involve them in decision-making processes regarding their discharge and ongoing care. Emphasise co-production.

Improved coordination: Enhance communication and collaboration between health and social care teams to ensure seamless transitions for patients.

Addressing negative language and blame: Avoid stigmatising language and focus on systemic improvements rather than placing blame on individuals.

Policy changes: Advocate for policy changes that support better integration between health and social care and prioritise long-term solutions over short-term fixes.

Multi-level action: Implement changes at individual, organisational, and structural levels to address the complex challenges of hospital discharge effectively.

Examples of initiatives and solutions/things that have worked in the past:

The Social Care Institute for Excellence has created a hashtag with personal stories from families.

Another example from the past is the work by the ‘Fife User Panels’ project.

Summary of second meeting

Following a session looking at the discussion materials, the second meeting covered the issues of communication gaps, discharge planning deficiencies, and assessment process challenges, which hinder the transition from hospital care to home. A concern highlighted across the Networks is the lack of effective communication among healthcare services, patients, and families, resulting in instances of medication mismanagement and inadequate consideration of individual needs during the discharge planning phase. Moreover, participants raised concerns about patients concealing their struggles during assessments due to fear of potential consequences, showcasing that an inclusive and open communication environment within healthcare settings is needed.

Moreover, an issue that was raised was poor discharge planning, including increased rates of re-hospitalisation, financial burdens on families, and adverse impacts on patient well-being. It is important to have designated points of contact and specialist advocacy to navigate the discharge process effectively. The lack of personalised planning is showcasing the importance of recognising each patient’s unique circumstances and needs. Concerns were raised about the insufficient planning for individuals with complex needs and the discomfort associated with labels such as ‘bed blocker,’ advocating instead for person-centred approaches to discharge planning.

Along with these challenges, the discussion included potential ways for improvement. There was a strong emphasis on holistic approaches to healthcare. Examples of effective strategies include specialised support services, digital technologies, and multi-agency collaborations to improve communication between healthcare providers.

The second meeting emphasised actions raising awareness, documenting good practices, and improving communication channels between healthcare stakeholders and the public. Initiatives include public awareness campaigns, documentation of successful interventions, and improved support for clinicians during admission and discharge processes. Moreover, there is a strong emphasis on advocating for advanced care planning and respecting individuals’ healthcare choices, as well as exploring alternative care options to mitigate the risks associated with hospitalisation.