Intended for healthcare professionals

Education And Debate The hospital of the future

Is bigger better? Concentration in the provision of secondary care

BMJ 1999; 319 doi: (Published 16 October 1999) Cite this as: BMJ 1999;319:1063
  1. John Posnett, director (
  1. York Health Economics Consortium, University of York, York YO1 5DD

    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.

    Summary points

    NHS managers have been subject in recent years to considerable pressure to increase concentration and trust mergers

    This pressure has been justified by a belief that larger hospitals lead to lower average costs and better clinical outcomes

    Evidence from research does not support any general presumption that larger hospitals benefit from economies of scale or that service concentration leads to improved outcomes for patients

    Service planners would do well to give more prominence to the importance of ensuring that hospital services are local and easily accessible

    Optimal hospital size

    Even the most committed believers accept that there is a limit to the operation of economies of scale. Otherwise, the most efficient solution would be to concentrate all acute hospital services for the United Kingdom at a new mega-hospital somewhere around Leeds.

    The empirical literature on economies of scale …

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