Care after hospital discharge in London: step-by-step checklist

Care after hospital discharge in London usually starts with a plan agreed by the ward team, and for many older people it includes up to six weeks of free reablement or intermediate care at home. Before your relative leaves, check that medicines, equipment, transport and any care visits are in place, and that you know who to call if things go wrong. Longer-term needs are then assessed at home, under the NHS “discharge to assess” model.

Live in West Sussex? Read our local guide: Recovering at Home After Hospital: How Reablement Works.

Arranging care in West Sussex instead? Read our guide: Hospital discharge from Worthing Hospital: what families need to know.

At a glance

• Most people go home under “discharge to assess”: they leave once they no longer need hospital care, and longer-term needs are assessed at home (DHSC, 2024).
• Reablement and intermediate care are free for up to six weeks in England.
• Hospitals usually give around 7 days’ supply of medicines (NHS.uk). Order repeats from the GP early.
• Families and unpaid carers should be involved in discharge decisions where appropriate.
• If you pay privately, visiting home care in London typically costs £30–£40 an hour as of 2026.

How does hospital discharge work in London?

NHS hospitals in England follow the government’s Hospital discharge and community support guidance (updated January 2024). The default is discharge to assess. Once a person no longer meets the criteria to stay in hospital, they should be discharged, and their longer-term needs assessed at home or in a community setting. Our hospital discharge and reablement hub covers every stage.

The guidance sets out four discharge pathways:

Many London hospitals work with a transfer of care hub or discharge hub, where NHS, council and voluntary sector staff plan discharges together. For example, Ealing Hospital’s hub aims to help patients leave “as soon and as safely as possible”, and Sutton’s Transfer of Care Hub follows a “Home First” approach.

Before discharge: the checklist

Use this list in the days before your relative leaves hospital. Ask the ward nurse or discharge coordinator anything you are unsure about.

Planning and communication

• ☐ Do you know the expected discharge date and time?
• ☐ Has your relative, and you as family carer, been involved in the discharge plan? The NHS says you should be, with the patient’s permission.
• ☐ Which pathway is planned: home with no new support, home with support, a community bed or a care home?
• ☐ Is there a written care plan, and do you have a copy?
• ☐ Who is the named contact if you have questions after discharge?

Care at home

• ☐ Has reablement or intermediate care been arranged? When is the first visit?
• ☐ If not, has anyone assessed whether help is needed with washing, dressing, meals or getting about?
• ☐ If your relative lives alone, who will be there on the first day and night?
• ☐ If private care is needed, has an agency been booked? Visits should start on discharge day.

Medicines

• ☐ Has a pharmacist or nurse explained each medicine, including any changes?
• ☐ How many days’ supply is being given? NHS.uk says usually 7 days.
• ☐ Has a repeat prescription been ordered from the GP? Some surgeries need up to 2 working days’ notice.
• ☐ Does anyone need to help with medicines at home? If a carer will help, it must be written into the care plan.

Equipment and home

• ☐ Has an occupational therapist checked whether equipment is needed (rails, commode, bed lever, walking frame)?
• ☐ Will equipment be delivered before discharge day?
• ☐ Is the home warm, with food in, and clear walkways?
• ☐ Is there a key safe, or a way for carers to get in?

Transport and paperwork

• ☐ How is your relative getting home? Hospital transport is usually only for people who meet medical criteria.
• ☐ Have you got the discharge letter? A copy goes to the GP.
• ☐ Are follow-up appointments booked?
• ☐ Have you been told what symptoms to watch for and who to call?

King’s College Hospital notes that the discharge process itself can take up to four hours, as several teams are involved. Pack a bag and plan the journey home accordingly.

What is reablement and who gets it?

Reablement is short-term, goal-focused support to help someone relearn everyday tasks such as washing, dressing and making a meal. Age UK says staff guide you through tasks to “rebuild your skills and confidence” rather than doing everything for you.

In England, intermediate care, including reablement, must be free for up to six weeks under the Care and Support (Charging and Assessment of Resources) Regulations 2014. It is free for up to six weeks, not a guaranteed six weeks: how long it lasts depends on need. Read our full explainer on reablement and the six weeks of free care.

Community equipment and minor adaptations costing £1,000 or less are also free.

In the first week at home

The first few days are when problems show up. Watch for:

• Confusion that is new or worse than before.
• Not eating or drinking enough.
• Falls or near misses, especially at night.
• Medication problems: missed doses, side effects, or confusion about changes.
• Wound, catheter or infection concerns.
• The family carer struggling to keep up.

If you are worried, contact the GP, the reablement team, or NHS 111. In an emergency, call 999.

Age UK runs a free advice line on 0800 678 1602, open 8am to 7pm every day of the year. Many London hospitals also have voluntary home from hospital services offering practical help for the first few weeks; see our guide to home-from-hospital services across London.

After the first weeks: longer-term care

Under discharge to assess, a proper assessment of longer-term needs should happen once your relative has had a chance to recover. This may include:

• a Care Act needs assessment by the council;
• a carer’s assessment for you;
• an NHS Continuing Healthcare assessment if needs are complex. The guidance says a full CHC assessment should normally take place in the community, not in an acute hospital;
• a financial assessment if the council will fund ongoing care.

Care after reablement may be means-tested. In 2026/27, the upper capital limit in England is £23,250 and the lower limit is £14,250 (DHSC). The value of the person’s home is ignored when care is at home. Read our guide on what happens when reablement ends.

What does private care after discharge cost?

Some families arrange private care to start on discharge day, to top up reablement, or because they don’t qualify for council support. As of 2026, typical London prices are:

Sources: The Care Panel analysis of provider and marketplace prices, including Lottie (September 2026) and London provider price lists. Sources vary, so always get a written quote. Thirty-minute visits often cost 20–30% more per hour than longer visits.

If you need care to start fast, our guide to urgent home care in London explains what agencies need from you.

What if you’re unhappy with the discharge?

If you think your relative is not safe to go home, say so clearly and early.

• Speak to the ward nurse in charge or the discharge coordinator. Explain your concerns.
• Ask for the plan in writing, including what support is arranged.
• Contact PALS (the Patient Advice and Liaison Service) at the hospital if concerns aren’t resolved.
• Make a formal complaint to the hospital trust if needed.

The NHS says an independent advocate can help the patient express their views if they need support.

Frequently asked questions

What care is available after hospital discharge?

Many older people get free reablement or intermediate care for up to six weeks, to help them regain independence at home. Some go to a community bed for rehabilitation first. Longer-term needs are then assessed by the council and, if needs are complex, the NHS. Families can also arrange private home care to start straight away.

Is care after hospital discharge free?

Reablement and intermediate care are free for up to six weeks in England, and so are community equipment and minor adaptations costing £1,000 or less. After that, council-funded care is usually means-tested. NHS Continuing Healthcare is free if the person is eligible. Private care is paid by the family.

Can the hospital discharge someone who lives alone?

Yes, if they are medically fit and a safe plan is in place. That might mean reablement visits, a personal alarm, equipment and help from family or a home from hospital service. If you believe the plan is not safe, tell the ward team before discharge and ask for your concerns to be recorded.

How much notice will we get before discharge?

It varies. Discharge planning should start early in the stay, but the final decision is often made at short notice once someone is medically fit. Ask the ward for an expected date as soon as possible, and start lining up support, including any private care, before the day.

What if my relative needs more help after reablement ends?

Before reablement finishes, the team should review progress and talk about ongoing needs. The council can carry out a Care Act needs assessment and financial assessment. If your relative isn’t eligible for council funding, or you want more hours, you can arrange private care.

Sources

• GOV.UK: Hospital discharge and community support guidance
• NHS England: Model discharge pathway
• NHS.uk: Being discharged from hospital
• King’s College Hospital NHS Foundation Trust: Leaving the hospital
• West London NHS Trust: Ealing Hospital discharge hub
• Sutton Health and Care: Transfer of Care Hub
• Age UK: Support after hospital discharge
• legislation.gov.uk: Care and Support (Charging and Assessment of Resources) Regulations 2014, reg 3
• DHSC: Social care charging 2026 to 2027
• NICE NG67: Managing medicines for adults receiving social care in the community
• Lottie: Care at home costs
• Certified Care: Home care costs in 2026

This guide is general information, not financial, legal or medical advice. Last reviewed September 2026.

Reviewed by The Care Panel team on 24 September 2026. This guide is general information about care in England, not legal, medical or financial advice. Rules and rates change; check with your council or an adviser before making decisions.