‘Going Home’ Pilot Project Learning and Next Steps

Healthwatch Lambeth and Healthwatch Southwark jointly ran the Going Home pilot project to understand older people’s experiences of leaving hospital and recovering in the community. Between 2015 and 2017, the project followed nine older patients for up to 12 weeks after they were medically fit for discharge. Most participants were involved in pilot discharge-to-assess or step-down schemes based in extra care housing, while one person returned directly home after discharge. Interviews were conducted regularly with patients and, where appropriate, family carers to explore recovery journeys, transfer of care experiences and the effectiveness of support following discharge.

The project found that recovery was often far more complex than simply leaving hospital. Participants commonly experienced fluctuations in health, reduced mobility, medication problems, hospital readmissions and uncertainty about their future. Many reported feeling isolated, dependent and lacking control over what was happening to them. These emotional impacts affected both patients and family carers. While some people eventually achieved positive outcomes, such as moving successfully into extra care housing or regaining enjoyment in daily life, others continued to face persistent challenges including loneliness, unsuitable living arrangements, ongoing health issues and repeated contact with healthcare services. 

A major theme was poor communication during discharge and transition processes. Participants involved in the discharge-to-assess and step-down schemes often felt they had not been given adequate information about the purpose of the schemes, expected timescales, available support or what would happen next. Family members frequently felt unprepared for the responsibility of coordinating care, equipment, appointments and services once discharge occurred. Patients and carers often struggled to navigate complex systems involving multiple organisations, with examples of delays in district nursing visits, prescription arrangements and care coordination. Participants also wanted better information about medications, rehabilitation plans and available support.

Experiences within the extra care accommodation were mixed. Participants generally praised the quality of the accommodation and onsite care staff, but many felt uncertain about discharge planning and future arrangements. Some did not engage with activities or services because of poor mobility, lack of information or feeling like temporary residents. Care often focused on meeting immediate needs rather than actively promoting independence and reablement. Social workers were viewed as the most important coordinators of support, although participants sometimes found them difficult to contact. Many expected a more proactive role from their GP after discharge. 

The project generated practical improvements during the pilot itself, including referrals to services, action on environmental concerns and feedback to providers about communication issues. Findings informed improvements to the Southwark step-down service, contributed to the development of a welcome pack for participants, supported a major transfer-of-care quality summit and helped shape a carers training programme. The project also produced a training film that was subsequently used by healthcare providers, commissioners and regulators to improve understanding of discharge experiences. 

Healthwatch concluded that discharge and recovery should be viewed as an extended journey rather than a single event. The findings highlighted the importance of clear information, coordinated support, carer involvement and helping people regain control and independence following a hospital stay. The project demonstrated that patients and families often require support long after discharge has taken place and that listening to their experiences can help improve the design of health and social care services.