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April 13, 2026

Essential Partners: Transforming Carer Support During Hospital Discharge

When a patient is admitted to the hospital, the focus is naturally on their clinical recovery. however, for the "unpaid carer"—the family member or friend waiting at home—the journey can be overwhelming and isolating. In Dundee, a significant gap was identified: unpaid carers were often not identified until the very point of hospital discharge, or sometimes not at all.

Without early involvement, carers often felt unprepared, leading to higher stress levels, a lack of support, and an increased risk of the patient being readmitted to the hospital shortly after going home. The challenge was to move carer identification to the very start of the hospital journey.

Supported by funding from the NHS Tayside Charitable Foundation, the Dundee Carers Centre established a dedicated Development Worker role. This role was designed to "bridge the gap" between clinical staff and unpaid carers.

Key initiatives included:

  • Early Identification: Working to identify carers within 24 hours of a patient’s admission.

  • Ward Integration: Joining weekly "ward huddles" in Wards 3, 4, and the Royal Victoria Hospital to keep carer support at the forefront of staff's minds.

  • High Visibility: Introducing recognizable branding and polo shirts so that the Development Worker became a familiar, approachable face for both staff and families.

  • Direct Advocacy: Acting as a voice for carers like "Carer A," ensuring their concerns about a loved one's mental health or cognitive decline were heard by the multi-disciplinary medical teams.

The project has delivered measurable success in a remarkably short timeframe. Between November 2024 and September 2025, the project achieved:

  • 119 Carers Identified: A massive 600% increase in monthly referrals, growing from just 3 in December to 21 by July.

  • Reaching the "Unreachable": Notably, 91.6% of the carers identified were previously unknown to carer services, proving the project is reaching those most in need of help.

  • Meaningful Referrals: Carers were signposted to vital services including "Carers Money Matters" for financial advice, "Short Breaks" for respite, and "Self-Directed Support" for long-term care planning.

By recognizing unpaid carers as "essential partners" in the care journey, the project has strengthened the entire healthcare system in Tayside.

  • Reduced Anxiety: For families like "Carer B," who was struggling with the logistics of a newborn and a mother in rehab, the project provided clarity on transport and communication, lowering the emotional toll of the transition.

  • Empowered Voices: Carers now have a formal seat at the table during discharge planning, ensuring that the move from hospital to home is safe, sustainable, and person-centered.

  • Staff Awareness: NHS ward staff are now better equipped and more confident in identifying carers early, creating a more compassionate culture within the hospital.

Looking Ahead

The work is far from over. Based on the success of the initial phase, the project aims to further embed carer support into the digital fabric of the NHS. Future goals include integrating carer identification directly into NHS Trakcare systems and expanding the team to include a full-time Support Worker.By continuing to invest in this role, the Foundation is helping to build an integrated care pathway that supports the patient by supporting the person who cares for them most.Strengthen national research programmesAccelerate safe innovation within the NHSThe success of this study also highlights the future potential of advanced skin-testing technologies to improve treatments for a wide range of skin conditions.Thanks to NHS Tayside Charitable Foundation supporters, research like this can move from theory to real-world impact — improving care today and preventing illness tomorrow.

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