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Objective-To evaluate the effectiveness of the role of a discharge coordinator whose sole responsibility was to plan and coordinate the discharge of patients from medical wards. Design-An intervention study in which the quality of discharge planning was assessed before and after the introduction of a discharge coordinator. Patients were interviewed on the ward before discharge and seven to 10 days after being discharged home. Setting-The three medical wards at the Homerton Hospital in Hackney, east London. Patients-600 randomly sampled adult patients admitted to the medical wards of the study hospital, who were resident in the district (but not in institutions), were under the care of physicians (excluding psychiatry), and were discharged home from one of the medical wards. The sampling was conducted in three study phases, over 18 months.Interventions-Phase I comprised baseline data collection; in phase II data were collected after the introduction of the district discharge planning policy and a discharge form (checklist) for all patients; in phase III data were collected after the introduction of the discharge coordinator. Main is crucial for good quality inpatient care and timely discharge from hospital. Good quality hospital discharge can be defined as patient satisfaction with involvement in the process of discharge, the absence of problems after discharge and the assessment, documentation, and meeting of the need for community care after discharge.A recent report from the National Health Service (NHS) Executive recommended that discharge coordinators should be appointed in hospitals to facilitate discharge planning.' An effective discharge planning process may be described as the construction and implementation of a planned programme of continuing care which meets a patient's needs after discharge from hospital. An adequate system of assessing patients' needs should also maximise the efficient use of hospital beds by ensuring that patients are not in hospital for an inappropriate time, or discharged with inadequate notice for the organisation of their continuing care at home. Essential elements of effective discharge planning are a multidisciplinary approach, early and coordinated assessment of a patient's needs and home circumstances, early planning of needs for further care, and effective communication. There is some evidence that the strict application of criteria for inpatient stays, reviewed daily by medical staff for each patient, can reduce the duration of stay.

Evidence regarding the relationship between outcome and the number (volume) of patients treated at individual hospitals or by individual surgeons is reviewed and the interplay of other factors such as hospital characteristics, population profiles and referral preferences examined. An inverse relationship between mortality rate and hospital volume has repeatedly been found and, while there have been similar findings for surgeon volume, these results have been less consistent. What is certain is that wide variation in outcome does occur. What is less clear is whether the relationship to volume is a causal one or whether it is due to other factors such as those mentioned above. Despite there being a great deal that we do not understand about these relationships, considerable action has been taken as a result of the studies reported here, in the USA in particular. This has taken the form of rationalization of services, publication of hospital mortality rates and the setting of minimum numbers of specific procedures that should be performed each year by individual surgeons. Understanding of this area should be much greater before rationalization is considered in the name of higher quality and before mortality rates according to hospital or surgeon are published.

There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.

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