When big may not be beautiful

“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, …