One of the current obsessions of the NHS is with economies of scale – the notion that health care would be safer, faster, cheaper and more efficient if services were provided by larger teams in bigger hospitals or across ever-enlarging networks of organisations. This could be seen as an extension, albeit in a mutated form, of the decades-long drive towards the centralisation and specialisation of hospital services.
To these ends, over half of all hospitals in England have been closed or merged in the last 20 years, while one of the purposes of sustainability and transformation partnerships is to create unprecedented economies of scale at regional level across every type of NHS organisation.
One of the consequences of this trend has been to make the smaller hospital seem a near irrelevance in the NHS landscape. Yet smaller hospitals provide care to nearly half the population of England in communities that are frequently rural and/or remote, are more deprived, and with a patient cohort that is older and more co-morbid than average.
These hospitals also face more significant challenges than their larger, more urban counterparts. They are more likely to suffer from workforce shortages, a more constrained financial environment and a lack of the highly specialist services that the public increasingly expects. Many of them are plagued by the existential threat of closure, which makes planning and recruitment an even more difficult task.
Analysis last year by the Nuffield Trust showed that six of the seven most remote rural trusts in England accounted for nearly a quarter of trust deficits, reflecting their higher and often unavoidable costs.
Yet the game for smaller hospitals is not completely over just yet. There is an increasing awareness of their importance internationally, especially in widely geographically dispersed countries such as the USA, Canada and Australia.
In England, the NHS Long Term Plan acknowledged the problems of smaller acute hospitals, including the fact that many “national standards and policies [are] not appropriately tailored to meet their needs”, and pledged to work with trusts on new operating models and developing better links with other parts of local systems.
This has been extended to consideration of specific needs of smaller, rural and remote hospitals with regard to workforce planning and postgraduate education.
For some smaller hospitals, their need is urgent and these structural changes cannot come fast enough. I hope that the evidence presented in the special edition of Future Healthcare Journal will underline just how important smaller hospitals are in the wider economy. They are deserving of support at every level, if fair and equitable care is to be delivered to all across the NHS.
We hope that clinicians and managers will find the edition useful in improving day-to-day care, as well as calling to the attention of our political masters the importance of formulating policies and supporting practices that will able enable smaller hospitals to continue to provide the care that their local populations deserve.
Louella Vaughan is a senior clinical research fellow at The Nuffield Trust, consultant physician in acute medicine at The Royal London Hospital, and a member of the Future Healthcare Journal editorial board. This is an abridged version of her editorial in Future Healthcare Journal volume 7, issue 1, February 2020.
Vaughan L (2020) "Why bigger isn’t always better: Caring for patients in smaller, rural and remote hospitals", Future Healthcare Journal editorial / “Smaller hospitals: deserving of support at every level”, Nuffield Trust comment.