Anticentralisationarianism [neologism] in the UK. Viva la generalist!

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Vaughan L, Edwards N. The problems of smaller, rural and remote hospitals: Separating facts from fiction. Future Healthcare Journal. 2020 Feb;7(1):38.

Open Access link

UK small hospitals are not small by NZ standards but this is still a very relevant summary of the literature that challenges the assumptions health planners make about the merits of centralisation and specialisation. I recommend this paper to all of you in clinical leadership or management positions. For everyone else at least read the sections on ‘The unrecognised problems of closure’ and ‘smaller hospitals and social justice’. Rural hospitals are not just little urban hospitals and they have quite a distinct role in the social and economic fabric of the communities they serve. This follows on nicely from Kati’s recent paper in the NZMJ (Open Access full text available in 6 months time)

Comment by Associate Professor Garry Nixon

This article comes from a themed edition of the Future Healthcare Journal. It is open access.

Take home points

Moreover, while doctors and managers frame arguments about services in terms of quality, safety, cost and efficiency, patients and other community stakeholders have entirely different sets of concerns.

Instead, they view local access to hospital services as a ‘self-evident good’, and consider that most problems could be solved with appropriate resources.

They are clear about the burdens imposed by increased travel time and isolation from friends and family. The role of the hospital in the community is also critical – not only were hospitals frequently the largest employer in the area, but they were imbued with substantial political and symbolic power of the importance of the area in the wider context.

These and other arguments about the disbenefits of hospital closure are rarely discussed in the medical context

Hospital or service closures do not remove risk, but rather transfer the risk from the healthcare system to patients and their families.


Smaller hospitals internationally are under threat. The narratives around the closure of smaller hospitals, regardless of size and location, are all constructed around three common problems – cost, quality and workforce. The literature is reviewed, demonstrating that there is little hard evidence to support the contention that hospital merger/closure solves these problems. The disbenefits of mergers and closures, including loss of resources, increased pressure on neighbouring organisations, shifting risk from the healthcare system to patients and their families, and the threat hospital closure represents to communities, are explored. Alternative structures, policies and funding mechanisms, based on the evidence, are urgently needed to support smaller hospitals in the UK and elsewhere.

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