Letters: New models for small hospitals

Nigel Edwards' article, 'Models of perfection' (page 24, 4 June), contains a mass of densely-compressed evidence and comment on the possible future roles of small general hospitals. However, perhaps because of space restrictions, he only made passing reference to the context in which they might operate, referring to their impact on the 'hospital that will be at the hub of services.'

We have consistently advocated the necessity for a comprehensive model that embraces a central component for complex services and those requiring a concentration of high-level skills, together with a distributed locality element dealing with relatively straightforward elective work, largely as day cases.

Such a model, however, should be constructed on a larger population base than has been the norm. This is because larger populations - of 500,000 or more - are required to generate sufficient workload to maintain clinical expertise in the sub-specialties. But unless the central and locality provision is seen as part of a single system, with a unified clinical staff serving both elements, a two-tier system will result. Clinical staff serving local requirements would be perceived as 'second-class', with consequential recruiting difficulties.

The changing role of junior doctors, resulting both from the reduction in their working hours and the demands of their training, will make it unrealistic to envisage them having an outposted, unsupervised role as residents in locality hospitals; thus proposals for overnight stays by patients whose condition requires medical supervision are not practical.

Nigel Edwards' wide-ranging article demonstrates the broad scope and large volume of work that can properly be undertaken locally, so that further and potentially dangerous expansion is not needed to justify an effective function for locality hospitals, which can and should be retained, but within a bigger system.

Ronnie Pollock MPA Health Strategy and Planning London NW1