Smaller local hospitals will be supported to develop new roles at the heart of local communities Health Secretary Alan Milburn announced.

New guidance issued today to the NHS challenges the mindset that 'biggest is best'. New resources and new models of care show that 'small can work', with the potential for a wider range of safe, effective, high-quality care to be offered in smaller hospitals than previously thought possible.

The guidance makes clear that technological developments - such as new equipment and new Information Technology - alongside changing workforce roles open up a new range of possibilities for smaller hospitals and localised services. This includes:

· increasingly sophisticated day surgery;
· exploring networking between small and large hospitals, including the potential of telemedicine;
· exploring new ways of providing hospital services at night.

The guidance outlines some of the ways local hospitals can be helped to provide patient-focused care while ensuring staff are supported to work safely without excessive workloads. It is based upon three core principles the NHS will in future need to follow when considering proposals for change in local hospitals and other services:

· developing options for change with local people, not just for them.
· focus on redesign not relocate. Redesign can offer a high quality alternative to relocating services, extending the range of options for developing new configurations that meet local needs and expectations;
· taking a whole systems approach developed across health and social care communities rather than for an individual hospital site, Trust or organisation.

The consultation in the document provides examples for new models of sustaining smaller hospitals. These include:

· Emergency medical and surgical care: one option enables 24 hour emergency access to medical and surgical care, by using the available trainee and career grade doctors and consultant medical staff more effectively;
· Local emergency care: proposed models of care in which patients receive rapid assessment in a local hospital, with doctors from the nearest larger acute hospital site advising remotely via a telemedicine link. Based on this assessment patients requiring more intensive acute care would be transferred to the larger hospital for direct admission to wards, avoiding the need for a further wait in A&E.

Some of these approaches are already established or are being planned elsewhere. Kaiser Permanente in California has shown the benefits of integrated care. At the Aberdeen Royal Infirmary in Scotland, the Scottish Telemedicine Action Forum has funded the provision of telemedicine links with a number of community hospital A&E facilities to help treat patients in remote locations.

The hospital models are being piloted in the NHS at Central Middlesex, Bishop Auckland and West Cornwall and the National Co-ordinating Centre for Service Delivery and Organisational Research and Development programme is commissioning an independent evaluation of these sites.

Health Secretary Alan Milburn said:

"Patients want more, not fewer, local services. Changing local health services does not necessarily mean centralising services, with fewer, larger 'super hospitals'. New resources combined with reforms to the way care is delivered mean greater emphasis can now be placed on the role and importance of smaller hospitals. This document shows how modernisation and improving the quality of care are about working with local communities and staff to build services around patient needs. Medical advance and other developments mean that change must go on in local health services but for too long, the presumption has been that biggest is always best when it comes to hospital services. The starting point should be to examine how to keep as many services as local as possible."

Copies of the full document Keeping the NHS Local: A New Direction of Travel are available to download from the internet at www.doh.gov.uk/configuringhospitals

The consultation period will last for three months to 14 May 2003.