Hospitals: is bigger better?

In the latest edition of our Insight magazine, we talk to Nigel Edwards, Senior Fellow at The King's Fund, about the problems often faced by smaller hospitals and how these problems could be overcome.

What does the future of small hospitals look like?

The future of small hospitals has long been an issue for debate and the pressure on these organisations to demonstrate their viability is increasing. The debate is now extending to what many would consider to be medium-sized hospitals. The number of people a hospital serves to be considered small has risen from 150,000 to 250,000.

'There's a mythology of sorts that has grown up around the minimum viable size for a hospital,' explains Nigel. 'There is a feeling among those in small and medium-sized hospitals that the goalposts keep shifting.

'These hospitals often carry out a high proportion of emergency work, which is low margin under the tariff (the system by which hospitals are paid for much of their activity). Non-tariff income such as research, teaching and some specialist services, can be higher margin, but small hospitals usually have a lower proportion of this.'

Is centralising services the answer?

One response can be to centralise services and this approach is supported by improved clinical outcomes for some specialities such as major trauma and cancer. But could this cause more problems for those left behind?

'If a hospital loses surgical services, it is very likely that this will have a detrimental impact, as patients who might need surgery won't be referred anymore. We need to be thinking about how primary and community care work alongside these hospitals; we can't think about hospital redesign without doing this.'

Creating new models of sustainable care

The challenge is that providers are grappling with these problems now and can't rely on the possibility of future changes in primary care. This is why Nigel is facilitating a learning set for leaders from small and medium-sized hospitals to help create new models of sustainable care.

'Faced with these challenges, there are many exciting ideas from these leaders about how they can respond,' says Nigel. 'These include providing community services, running virtual wards and extending what they do outside the hospital. There are more flexible and imaginative ways to staff hospitals, too; for example, using a risk-based approach to care, rather than relying on a silo-based, professional model.'

'Talking about barriers and exploring new models of care is essential. Some of these are award-winning hospitals; we need to look at ways of harnessing that expertise in new models of care which are sustainable and focus on the needs of patients.'