Views & Reviews The Bigger Picture

How to get out of hospital

BMJ 2013; 347 doi: (Published 25 September 2013) Cite this as: BMJ 2013;347:f5788
  1. Mary E Black, global health doctor, London
  1. drmaryblack{at}

Many patients in hospital in the United Kingdom would love to leave. These are noisy, fractious places where you’d never choose to be unless you really had to. And nowadays I am pleasantly surprised when anyone with complex needs actually gets out of hospital at all.

Many patients with multiple health and social care needs, often elderly and frail people, would be only too keen to get home if they could. But gone are the days of my medical youth when I could simply call the relatives to ask them to collect the patient or I could send the patient to a nursing home.

Today, patients are tangled up in long elastic bands. A discharge team pulls on a patient’s band with all its might, battling dozens of pages of discharge protocols, a complex interface between hospital and community services, and various stages of approval and checking by commissioning support units and clinical commissioning groups. The team strains away, slipping at times as the paperwork tries to move beyond “incomplete,” costs are ratified, and family members are given options—and everyone tries to arrive at an elegant weekday discharge time. But often the elastic band ricochets back to its default position, and the patient remains in hospital. So the team has to regroup and start pulling again.

Eventually, something gives and the patient goes home. However, the tension in the elastic band remains, and the default is still to ping the patient right back into a hospital bed. All it takes is one phone call to emergency services from a concerned district nurse or a tired relative, a general practitioner who thinks the patient might be better off back in hospital, or simply anyone in the long and complex caring chain being overcautious.

I admire our discharge teams, who work ever harder to increase efficiencies in this profoundly stupid system. In other, faraway lands are health maintenance organisations and insurance companies which just will not authorise another day in hospital. In the UK the public purse funds separate health and social care economies, and the sooner we tackle this the better. We need joined up social care and healthcare budgets and an end to the nonsense that keeps some people in hospital against their will and against common sense.

We need financial incentives to keep people out of hospital and care for them in the community. Until then we will waste much energy stretching pointless elastic—while patients are left in a tangle.


Cite this as: BMJ 2013;347:f5788


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I have worked as an international health consultant for Unicef, HLSP, CA Legal, and national governments.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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