A close observer of the NHS over the past 10 years might be forgiven for thinking that the debate about the concentration of acute hospital services has been driven more by the needs of NHS managers and the medical professions than by the needs of the local populations that they are supposed to serve. Managers have faced pressures to reduce unit costs and, in particular, the “wasteful” costs of management itself. The medical professions, through their respective royal colleges, have encouraged the closure or rationalisation of smaller units through pressures for greater subspecialisation.

The result has been pressure for further concentration in the provision of hospital services through rationalisation and trust mergers. The logic is inescapable: larger units reduce average costs through the operation of economies of scale and larger units improve patient outcomes by increasing average volumes of activity by clinicians. Unfortunately, this logic is not supported by the evidence.