The financial pressures facing the national health service (NHS) in England, coupled with changes in medical practice, are raising fundamental questions about the current configuration of acute hospitals. With some services being provided in people's homes and in primary care, and others being concentrated in specialist centres, the viability of the current network of district general hospitals is in doubt.

If the closure of entire hospitals is likely to be the exception rather than the rule, many hospitals will have to reduce the range of services they provide to adjust to changes in their environment. This was acknowledged by David Nicholson, the newly appointed NHS chief executive, in a recent letter to MPs in which he emphasised, “Our aim should not … be to preserve the status quo, but to think imaginatively about how we can unlock the resources, both in terms of …