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EDITORIALS: Pam Garside Evidence based mergers? BMJ 1999; 318: 345-346 [Full text]

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Evidence based mergers?

Alasdair J Macdonald   (9 February 1999)

Garside's editorial is incomplete and confuses outcomes and process

Trevor Sheldon, Alan Maynard   (8 March 1999)

Evidence based mergers? 9 February 1999
Alasdair J Macdonald Send response to journal: Re: Evidence based mergers?	EDITOR- Pam Garside (1) comments on merger mania. Trusts were imposed as part of a cost control system imported from the USA, those responsible having failed to see the structural difference between a money-based system and a centrally-funded social medicine system. Trusts were expensive to establish and to run and have been divisive in their effect. They have never been commercial operations in any true sense: a sizeable proportion have been technically bankrupt for more than two years. Merger pressure comes from central government and is a tacit acceptance of the failure of the Trust concept. Merger has no relationship to commercial drivers in the usual sense. Alasdair J Macdonald Consultant psychiatrist Garlands Hospital Carlisle CA1 3SX 1 Garside P. Evidence based mergers? BMJ 1999;318:345-6
Garside's editorial is incomplete and confuses outcomes and process 8 March 1999
Trevor Sheldon, Directors of York Health Policy Group University of York, Alan Maynard Send response to journal: Re: Garside's editorial is incomplete and confuses outcomes and process	Editor - Garside's editorial (6 February 1999) on evidence based mergers is incomplete and confuses outcomes and process. She wants to collect evidence on ‘how to manage the process of merging' as well as assemble ‘evidence on the benefits of NHS merged organisations'. Firstly the international evidence on the benefits of mergers and the influence of hospital size on the quality, cost and access to care has been extensively reviewed by the NHS Centre for Reviews and Dissemination1, 2 and published in a book.3 This indicates (i) unit costs fall little beyond 600 beds, (ii) quality (in terms of mortality) can sometimes, but may not always, be improved by increased volume, and (iii) concentrating services increases travel costs for patients and carers, affecting access and use differentially in terms of social class. In the USA mergers mania is largely the product of ‘an oligarchy of executives who are reacting to the vicissitudes of the market place'.4 Policy makers in the UK may also use service reconfigurations as a smoke screen behind which to reduce bed numbers. The best way to judge the process of merging is surely in relation to cost, quality and access: do mergers produce better outcomes in these three respects? Of course these may not be the goals of politicians. They may use mergers as crude methods for disciplining obdurate clinicians and weak managers who fail to control NHS resources efficiently. What is needed with mergers is surely a clear statement of goals and predicted outcomes with performance monitored openly by the Audit Commission. Only then can we augment the evidence base and distinguish between political ‘wheezes' and the wise use of scarce NHS resources. Yours faithfully, Professor Trevor Sheldon Professor Alan Maynard YORK HEALTH POLICY GROUP, IRISS D Block, University of York, Heslington, York YO10 5DD 1. Effective Health Care. Volume and health care outcomes, costs and patient access. Effective Health Care 1996; 2(8) 1-12. 2. NHS Centre for Reviews and Dissemination. Concentration and choice in the provision of hospital services. CRD Report No 8. York: University of York, 1997. 3. Ferguson B, Sheldon T, Posnett J. Concentration and choice in healthcare. Royal Society of Medicine Press Ltd, 1997. 4. Kassirer JP. Mergers and acquisitions - who benefits? Who loses? NEJM 1996; 334: 722-3.