Education And Debate

Reconfiguring health systems

BMJ 2002; 325 doi: (Published 30 November 2002) Cite this as: BMJ 2002;325:1290
  1. Andy Black, health services consultant and former NHS trust chief executive (
  1. Durrow, PO Box 22, Machynlleth SY20 8WQ

    Many doctors and other health professionals are engaged in discussions about reconfiguring health services, and in particular building new hospitals. Here Andy Black, a former NHS hospital chief executive, argues that in England at least discussions about reconfiguring health services are too dominated by discussions about buildings. We lack a vocabulary to discuss other ways of investing in health gain. Perhaps surprisingly, the problems of labour supply may stimulate the radical change that is needed

    At a seminar on “the hospital of the future” earlier this year, the Department of Health estimated that 75% of English hospitals were involved in some form of reconfiguration debate—that is, discussions about where and how secondary and tertiary services should be provided. The Royal College Physicians claims that 61 English hospitals are isolated, provide only acute medical services, and should therefore be “reconfigured.”1 Many English readers of this journal will be involved in these discussions. These discussions should also be familiar to health professionals worldwide—though the precise balance of problems and opportunities that I discuss here will differ from place to place.

    Summary points

    Discussions about reconfiguring specialist health services are dominated by ideas of centralising services in big hospitals—yet the public persists in valuing local services

    Investment in hospitals is well understood and professionals have good arguments for specialisation and centralisation

    The NHS has no mechanisms for encouraging or assessing different sorts of investment for health gain

    Labour supply problems and the promise offered by information technology may both force and enable future reconfigurations of services that genuinely improve health

    Why reconfigure?

    Health systems must balance two purposes. In the short term they must respond to the demands of the population for access to existing services. At the same time they must try to improve the health of the whole population: get the waiting list down …

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