The NHS is under unprecedented pressure. Hospitals are struggling to discharge patients who are medically fit to leave, with beds blocked and waiting lists swelling. In winter 2023-24 alone, nearly 272,000 hospital bed days were lost in England because patients were unable to leave, despite being ready to do so.
Each week, between 12,000 and 14,000 people remained in hospital awaiting discharge, at a cost estimated at £1.7bn in 2022-23. Beyond the financial strain, prolonged stays increase the risk of deconditioning, infection and delayed recovery, while also preventing others from accessing timely treatment.
Care closer to home
Against this backdrop, coupled with Government’s policy commitment, the case for delivering more care at home has become compelling. The shift to ‘hospital-at-home’ models and virtual wards is no longer theoretical. Across the country, local systems are piloting new approaches to deliver healthcare in people’s living rooms, rather than in hospital wards.
Homecare providers, long associated with supporting people with meals, mobility and companionship, are increasingly being asked to manage complex medication regimes, provide advanced dementia support, undertake catheter and stoma care, deliver reablement and even assist with palliative and end of life care. The home is rapidly becoming the new hospital, but the demands placed on providers and staff are changing in profound ways.
The transformation of homecare from task-based support to complex clinical care brings with it new challenges. Care workers are now expected to monitor long-term conditions, respond to deteriorations and collaborate with GPs, district nurses and discharge teams. One provider I worked with was asked to support a patient with both chronic obstructive pulmonary disease (COPD) and heart failure, who had been discharged earlier than previously possible.
The homecare team found itself responsible for oxygen therapy, symptom monitoring and daily liaison with health professionals to prevent readmission. Such scenarios are becoming the norm rather than the exception, but they raise fundamental questions about how ready the sector is to deliver this level of care safely and sustainably.
Promise and pitfalls
Enhanced care in the home does not simply mean scaling up what already exists. It requires a leap in clinical competence, with care workers trained to undertake procedures and monitoring tasks that once sat firmly within the NHS. Services must be responsive, flexible enough to intensify support as needs change and available around the clock. This kind of care also demands integration with NHS systems, so that data flows seamlessly between hospitals, GPs and care providers rather than being locked in silos. In addition, it calls for commissioning models that move beyond the traditional ‘time and task’ approach, recognising that the complexity of care and its outcomes matter more than simply the minutes of care delivered.
We do not have to look far to see both the promise and pitfalls of this shift. In one integrated care system (ICS) in the North West, a hospital-at-home pilot asked homecare providers to support patients with oxygen dependence after discharge. Over six months, the scheme reduced readmissions by a quarter and saved around 1,000 bed nights. Yet it also highlighted fragilities – staff needed ongoing clinical supervision, scheduling was difficult and data handovers with hospitals remained patchy.
In Suffolk, a more collaborative reablement partnership between a local authority, a provider and community health teams showed how co-design can make a difference. Staff were trained in advance, handover protocols were clear and outcomes such as readmission rates were actively tracked. Elsewhere, in a rural setting, the introduction of remote monitoring faltered when broadband connectivity failed. Staff reverted to paper logs and escalations were delayed, underlining how digital infrastructure cannot be taken for granted.
Delayed discharge caused by delays in social care packages has been tackled effectively by the Mid and South Essex NHS Foundation Trust. The Trust is saving 60 hospital beds a day thanks to an innovative service which minimises delays in discharge by providing a complete, therapy-led hospital discharge assessment at home as part of NHS-led domiciliary care provision prior to handover to social services.
Forging an inclusive path
Despite rhetoric about integration, homecare providers are still too often excluded from strategic discussions at the ICS level. Decisions about pathways, funding and digital rollouts are made without the input of those who will deliver the care day to day. This exclusion has real consequences – care workers frequently operate without full clinical context, training is inconsistent and funding is misaligned with the true complexity of what is being asked. Treating providers as contractors, rather than strategic partners, risks undermining the very models policymakers are trying to scale.
At the heart of readiness lies the workforce. Care work is already difficult and emotionally demanding. Asking staff to take on more clinical responsibility without investment in training, support and recognition is unsustainable and unsafe. For hospital-at-homecare to succeed, training must be seen as infrastructure rather than a cost.
Care workers need access to accredited, modular programmes that can be delivered flexibly around shifts, supported by clinical supervision and clear career pathways. Training must not be something squeezed in on the margins of stretched rotas but embedded as part of the role. Staff must also be recognised and rewarded for the increased complexity of their work, not left on insecure contracts that erode retention and morale.
Technology must help, not hinder
Technology will also play a central role in enabling hospital-at-home models. Remote monitoring, shared records and communication platforms can give care workers and clinicians real-time oversight, reduce duplication and help identify deterioration early. Yet digital tools succeed only when designed for the realities of care work, when staff are properly trained and when they are integrated with NHS systems such as GP Connect and shared care records.
Providers using homecare management software that integrates with GP Connect are finding that they save many hours each week with instant online data about patient records and test results rather than waiting on calls to GP surgeries. Yet many providers are still to sign up for the service. Technology should not add new burdens or create parallel systems that do not talk to one another. Instead, like GP Connect, technology can and should free care workers to spend more time with people drawing on care and support.
At the frontline, quality technology should be seen as an enabler of high-quality care. Too many providers still rely on paper-based systems, or inadequate software systems, which slow communication and risks gaps in information. Real-time data sharing already exists within some platforms, but true progress will come from seamless integration with the NHS and other key stakeholders. This level of integration is essential if homecare is to reach its full potential as part of a wider health and care system.
The elephant in the room
None of this is possible without addressing funding. Homecare remains funded primarily through short-term contracts and time-and-task commissioning, which fails to reflect the unpredictability and complexity of hospital-at-homecare. If providers are to invest in staff, technology and integration, they need longer term certainty and funding models that recognise outcomes, not just hours. Shared budgets between health and social care, complexity-weighted pricing and capital support for digital integration are all essential to making the model sustainable.
Greater investment is also needed to ensure vulnerable people receive the time and support they require. Beyond meeting immediate care needs, homecare can play a vital role in tackling issues such as social isolation, which remains a major challenge. Technology can help here too – bringing greater efficiencies along with freeing up staff from paperwork and administration, so more time can be spent building meaningful connections with people drawing upon care and support.
Running out of time
A positive future is within reach. We could see a workforce confident and proud to deliver clinical grade care in the home, recognised as professionals in their own right. We could see seamless integration between hospitals, GPs and domiciliary care, with fewer unnecessary admissions, earlier discharges and people supported where they most want to be. But achieving this will require courage and commitment. Homecare must be treated as a strategic partner, not an afterthought.
The sector is at a crossroads. The home is the new hospital, but unless we invest in the workforce, integrate providers into system design and align funding and technology with real-world needs, the model will falter. Care is becoming harder and more complex, and providers must be supported to rise to that challenge. The opportunity is there – but it will only be realised if we act decisively now.
Have you been expected to deliver complex clinical care in addition to your usual responsibilities? Comment on this feature or join the conversation to share your thoughts.
Merina Martin is a Homecare Champion at CareLineLive. Email: [email protected] X: @CareLineLive