Organizing hospitals into networks: a hierarchical and multiservice model to define location, supply and referrals in planned hospital systems

Health care planners in countries with a system based on a National Health Service (NHS) have to make decisions on where to locate and how to organize hospital services, so as to improve the geographic equity of access in the delivery of care while accounting for efficiency and cost issues. This study proposes a hierarchical multiservice mathematical programming model to inform decisions on the location and supply of hospital services, when the decision maker wants to maximize patients’ geographical access to a hospital network. The model considers the multiservice structure of hospital production (with hospitals producing inpatient care, emergency care and external consultations) and the costs associated with reorganizing the hospital network. Moreover, it considers the articulation between different hospital services and between hospital units, and the ascendant and descendent flows related to twoway referrals of patients in the hospital hierarchy. The proposed approach differs from previous literature by accounting simultaneously for these issues and provides crucial information for health care planners on referral networks, on hospital catchment areas, on the location and structure of hospital supply as well as on the costs required to improve access. The results from applying the model are illustrated in an application to the South region of the Portuguese NHS. Three scenarios are portrayed to describe how the model can be used in distinct institutional settings and policy contexts and when there is uncertainty concerning the key parameters of the model.