High Volume Low Complexity Surgical Hubs in England: Can They Improve Physician Productivity?

Abstract

Whether organisational separation of elective and emergency care improves physician productivity remains an open question. Most existing evidence relies on cross-sectional comparisons or volume-based outcomes that cannot isolate efficiency gains from input expansion or provider selection. In contrast, this paper exploits the staggered rollout of NHS England's surgical hub programme, a set of dedicated ring-fenced elective facilities introduced as part of its Elective Recovery Plan, to provide causal estimates of the effect of elective-emergency separation on physician productivity. Using this rollout to implement a heterogeneity-robust difference-in-differences design, we estimate the impact of hub adoption on physician productivity measured as cost-weighted elective output per unit of salary-weighted physician input. We find that hub adoption increases physician productivity by 14.5% relative to the no-hub counterfactual, accompanied by a 10-day (7.6%) reduction in average patient waiting times. The size of these gains depends on how completely elective care is insulated from emergency pathways. Standalone hubs situated on dedicated elective-only sites achieve relatively larger productivity gains than integrated hubs located within main acute hospital sites. Moreover, operating multiple hubs yields gains more than double the overall average, whereas a single hub shows no statistically significant effect. For health systems seeking to raise physician productivity and address elective backlogs, these findings suggest that how separation is implemented, not simply whether it is adopted, shapes the productivity gains it delivers.