Intended for healthcare professionals

Education And Debate The hospital of the future

Planning hospitals with limited evidence: a research and policy problem

BMJ 1999; 319 doi: (Published 20 November 1999) Cite this as: BMJ 1999;319:1361
  1. Nigel Edwards, policy director (,
  2. Anthony Harrison, fellow in health policy analysisb
  1. a NHS Confederation, London SW1P 4ND
  2. b King's Fund, London W1M 0AN
  1. Correspondence to: N Edwards

    This is the last in a series of seven articles

    Research into the running and planning of hospital services has been neglected. This is surprising given the importance of hospitals for the public, politicians, and the healthcare system (box 1).

    Box 1: The importance of hospitals

    • Hospitals account for 40-60% of health expenditure in the Organisation for Economic Cooperation and Development and over 70% in the former Soviet Union and eastern Europe

    • Hospitals have been subject to major changes—for example, in the United Kingdom bed numbers were reduced by 15.5% between 1987-8 and 1997-8. Hospitals are important symbols of civic pride1

    • Hospitals make a significant contribution to education and employment. In London, for example, it is calculated that the medical schools and their associated hospitals contribute up to £500m to the local economy2

    • In the United Kingdom, 20% of the population are admitted annually and over 25% use an accident and emergency department


    The articles in this series have shown that despite this importance there is a paucity of research and policy about how hospitals work, how they should be staffed, what size they should be, and how change can be managed. This article examines the main gaps in our knowledge about the future of the hospital sector identified in this series and examines the implications of this for policy and research (box 2).

    Summary points

    Hospital planning is done on the basis of limited research

    There is little evaluation of completed plans

    Many of the assumptions used are not stated clearly and are often based on limited or poor evidence—this applies to many of the arguments for increased centralisation

    The paradox of increasing admissions and falling bed numbers has contributed to the problems of responding to emergency care

    Planning needs to take into account the limited state of knowledge

    Box 2: Gaps in research

    There are many uncertainties …

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