Hospitals: is bigger better?

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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.'

This article appears in the summer 2013 edition of Insight magazine.


Jasvir Singh Grewal

Consultant Ophthalmic Surgeon,
Comment date
02 June 2015
I recently visited a premier hospital in India where they had deployed mobile eye hospitals that went out into the community and delivered eye clinics and cataract operations local to patients. This model could work well in the UK, moving away from traditional hospital based services, it tackles capacity issues in hospitals, large building costs and overheads, in addition it works in a more integrated way helping smaller acute trusts to work more closely with primary care services. Most encouragingly it takes the hospital services to the patient. This will be even more important considering exponential rises in the elderly population. Trusts would also attract greater visibility of their brand within the population they serve. Essentially staff working closer to their community will gain better knowledge of and communication with their consumers.

Guy Patterson

Project Manager,
Age UK
Comment date
19 August 2013
I recently visited an award winning small hospital and saw for myself how a team of dedicated health professionals can provide an excellent level of service on many levels, including surgery and other clinical procedures that we might normally associate with acute hospitals. I also understood that these facilities were under-utilised due a a lack of referrals. I suspect this situation is by no means confined to the hospital i visited and may be a function of its location etc, but i am also inclined to the view that the marketing of such facilities is poor and needs to be improved so that patients can make their own informed choices about where they wish to be treated.

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