Do small hospitals have lower quality? Evidence from the English NHS.

James Gaughan,Luigi Siciliani,Giuseppe Moscelli,Hugh Gravelle

doi:10.1016/j.socscimed.2020.113500

James Gaughan, Luigi Siciliani + Show 2 more

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https://doi.org/10.1016/j.socscimed.2020.113500

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Abstract

We investigate the extent to which small hospitals are associated with lower quality. We first take a patient perspective, and test if, controlling for casemix, patients admitted to small hospitals receive lower quality than those admitted to larger hospitals. We then investigate if differences in quality between large and small hospitals can be explained by hospital characteristics such as hospital type and staffing. We use a range of quality measures including hospital mortality rates (overall and for specific conditions), hospital acquired infection rates, waiting times for emergency patients, and patient perceptions of the care they receive. We find that small hospitals, with fewer than 400 beds, are generally not associated with lower quality before or after controlling for hospital characteristics. The only exception is heart attack mortality, which is generally higher in small hospitals.

Highlights

Quality of care is a key policy objective in health systems across OECD countries
We investigate whether small hospitals are associated with lower quality in England, thereby informing policy on hospital closures and reconfigurations
Results for Model 1, which includes only bed size categories, patient characteristics and year or quarter dummies, are in Tables 2a-2c In Table 2a having 400 or more beds is associated with higher overall Summary Hospital Mortality Indicator (SHMI) mortality, though the association is statistically significant at the 5% level for only one of the six beds-size categories

Summary

Introduction

Quality of care is a key policy objective in health systems across OECD countries. It is multifaceted: it includes clinical quality, patient experience (such as being treated with respect and being able to communicate and have a dialogue with the doctor), amenities, and health system responsiveness and availability of services (such as how long patients need to wait for health care) (Busse et al, 2019; De Pouvourville and Minvielle, 2003).Small hospitals, defined in the context of the English National Health Service (NHS) as those with under 400 beds, are regularly the subject of debate and policy intervention (Vaughan et al, 2018; Imison, 2018). One policy concern is that small hospitals are not able to exploit scale and scope economies to be financially sustainable (Monitor, 2014) and may provide lower quality of care, leading to higher mortality (overall and for specific conditions), higher hospital acquired infection rates, and worse patient perceptions of their care. This may be reinforced by greater difficulty for small hospitals in recruiting and attracting staff, managing a smaller pool of staff that guarantees 24/7 provision of emergency care, or investing in diagnostic services (Vaughan et al, 2018). Closure of small hospitals will have equity implications if patients have to travel long distances (Buchmueller et al, 2006) and have poorer access to care

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