When big may not be beautiful

British Medical Journal, Oct 24, 1998 by Nicholas Markham

"Why grandmother, what a big hospital you've got," said Little Red Riding Hood. All the better to serve the people," replied the wolf.

The virtue of the "big is beautiful" model of providing secondary health care is being extolled by many people. In particular the royal colleges seem to be swayed by the arguments that it makes sense to centralise scarce yet highly costly resources in large units and concentrate medical skills within them. And so it probably does for crowded towns and cities, but what of the sparsely populated rural areas?

Communities in such areas thrive on a proud tradition of parochial spirit, well established traditions, and an impressive sense of pride. They cherish their independence and are content that they remain relatively free from some of the social problems prevalent in big cities. The local hospital is highly regarded. It may serve only a population of 150 000 to 200 000, yet it can boast some of the most modern equipment available, while realising that it cannot deal with very specialised problems. Junior medical staff receive an excellent broad and basic medical training, but most of the care is provided directly by consultants and patients have a far greater chance of their appendix being removed and their diabetic ketoacidosis being managed by a consultant than in larger institutions.

The units in the hospital may be relatively small, but they are busy and thriving and patient satisfaction rates are high. Such hospitals have a comprehensive accident and emergency service--the alternative would be to force patients to travel long distances--and have on site the necessary cohort of physicians and surgeons to provide the requisite standards of care. These doctors are not simply manning triage stations--they have to be able to manage the vast majority of common emergencies, referring the more specialised cases to other traits.

No matter what the arguments might be in favour of retaining smaller rural hospitals, none would make sense if the quality of service that they provide was demonstrably poorer. Many people have tried to suggest that the bigger units with high volumes of work produce better results, but in these days of evidence based medicine we have to concede that this is not always the case. Any units which are underresourced and improperly supervised will not be able to match the best results, but reports do not show that, where right standards and facilities are provided in smaller units, results are necessarily poorer. Judgments as to the viability of any unit must be made on the basis of quality of the work it does and the standards it achieves and not simply on the economic arguments.

Over the past 20 years in north Devon we have been steadily expanding, refining, and developing our services for the unquestionable benefit of our local population. Yet now we face our severest challenge. Because of royal college edicts our hospital is to be slowly dismantled as more and more services are moved to larger hospitals over 50 miles away. The local population has not yet felt the effects of this fragmentation, unlike the staff, whose morale has begun to plummet. We have worked hard to provide a high quality, well audited service and been able to show by such audits that standards and outcomes are equal to those of bigger institutions. We do not want to stifle progress or to argue against the need to improve standards, but we must begin our rearguard action before irreparable damage occurs.

We can achieve this in several ways. Firstly, we must challenge the royal colleges' guidance and recommendations. The key to monitoring standards of health care is careful audit of outcome. A comparison of large and small units should reassure us that high quality can be maintained whatever the size. Secondly, we must challenge the colleges' assumptions that training opportunities here are poor. Reports consistently show a high satisfaction rate among junior doctors working here, where the range of experience is broader and the teaching more comprehensive. Finally, we must be prepared to look at all the options and to consider different solutions--provided that the local community retains an adequate level of health care and that the scope of the services offered is not curtailed to the point where it affects safety or fails to attract the high quality staff that such units require.

I did all my training in large cities, but I have never regretted moving to this lovely rural area and I believe the quality of service that patients receive is equal to anything that can be provided in the large centres, except for the most complex of cases.

When the wolf comes to "huff and puff" I hope that the "house" that it seeks to blow down is not one built of straw but of unyielding bricks built on a solid foundation.

If you would like to submit a personal view please send no more than 900 words to the Editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR or e-mail editor@bmj.com

Nicholas Markham, consultant surgeon, Barnstaple