Mapping the Journey: Involving Carers in Hospital Discharge Learning Session, June 2023

We held an online learning session in the summer, exploring current practice in the involvement of carers in hospital. Bringing together an audience of hospital staff, including discharge leads, local carer leads, carer centre managers and carer support workers. Carers with lived experience of discharge were also invited to add their views on where improvements might be made and to remind us of the impact on carers.

Our Audience

81 colleagues from health and social care with an interest in improving how unpaid carers are involved in hospital discharge joined us on the day. 

  • 14 attendees from carers centres and carer organisations
  • 20 attendees from HSCPs
  • 42 attendees from NHS Boards
  • 5 attendees from national organisations such as COSLA, NES and Scottish Government 

Overall, 27 HSCP areas were represented at the event. 

Presentations: Good Practice, Service Design & Planning for Change

The morning session involved presentations from Healthcare Improvement Scotland’s Unpaid Carers Improvement Programme, Service Design and Strategic Planning teams. You can watch these sessions here:

Opportunities for Improvement

In the afternoon, we held a series of workshops asking participants about current practices in their local areas, what was working well and what could be better with regard to identifying, involving and supporting carers in hospital. A number of opportunities for improvement were identified.

Opportunities: Identifying Carers
  • Good communication with initial conversations, availability of paper-based and electronic information, sharing knowledge amongst professionals and clear expectations of journey for patients and carers.
  • Raising awareness for staff (their legal obligations) and carers (their rights).
  • Carer-dedicated roles are visible, with clear responsibilities and included in all planning conversations.
  • Consent for patient and carer.
  • Identification at the earliest opportunity, with referral for support during hospital discharge process where needed.
  • Joint working effectively between care teams/wards and NHS, social care and third sector such as carer centres. The right people in the right place to support carers.
 Opportunities: Involving Carers
  • Consistent communication, guided/structured conversations, timely provision of information relating to discharge, listening to carers and using those conversations to inform planning for discharge.
  • Availability of Information on support, processes, expectations, pathways, Planned Date of Discharge and Adult Carer Support Plans.
  • Carer involvement on the ward as an opportunity for the carer to continue to care for the patient where they want to.
  • A referral system for support during and after discharge planning.
  • Clarity of responsibility regarding who has it and at what stage.
  • Recording information gathered from carers, what’s used to make decisions and to carry out actions.
  • Raising awareness of policies, discharge pathways and processes.
  • Upskilling carers, supporting carer ability and confidence in carrying out simple procedures (if they wish to) to support early identification and prevention of for example potential infection.
  • Confidentiality for carers.
  • Technology for communication with carers, information on available support, referral to community support.


Opportunities: Supporting Carers
  • Advocacy for carers
  • Consideration of carer voice and views with carer support roles present and sharing information at MDTs and patient conversations, representing the carer view.
  • Dedicated carer support roles available in hospital.
  • Early & effective communication with carers & patients eg. face-to-face, phone, via digital apps, awareness of extended family. Conversations held at the right time and in the right place, with consideration for confidentiality and consent of the carer. All conversations are two-way dialogue between professional & carer.
  • Feedback for improvement: listening to carers and staff on how to best involve carers in discharge planning and taking appropriate action.
  • Signposting is clear, visible, and a referral system for support is in place.
  • Timely information sharing: agreements between agencies, consent from carers/patients, and from carers to discharge teams.
  • Support plans for carers, with information provided regarding Adult Carer Support Plans and Young Carers Statements and services available to help support carers in their role.
  • Recording of information gathered from carers, ensuring that systems are in place to do this and there is timely information-sharing between professionals.
  • Referral for ongoing support including support plans, registration with carer centre, maximising benefits, aids and adaptations, funding and access to short breaks.
  • Relationship-building, with staff given time to invest in this with carers.
  • Training for staff on how to have good conversations.
  • Sustainable funding, flexible and based on carers’ needs.
  • The right team around the carer: carer support worker, ward staff, social work, occupational therapy, Allied Health Professionals, pharmacists, volunteers.
  • Co-designed support for carers: person-centred, from pre-hospital stay to post-discharge, information on short breaks, practical support such as the use of volunteer service for help with luggage and transport etc.
  • Planning and system design: understanding who does what, where and when, identifying any gaps, and commissioning new services co-designed with carers.


Next Steps

Data gathered at this event has been informing the development of a change package for involving carers in hospital discharge. The change package will be tested at two test sites during 2024.

Our next learning session will take place in March 2024.

Contact us

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