My most insistent question when starting to write the PhD proposal was how it is possible that large investments are made in mergers and new hospital facilities, that from research and my own observations these investments did not seem to add value, while at the same time there is pressure on hospitals to be more cost effective. That just does not make sense. But, since this seems to be happening in many hospitals, I concluded there must be other explanations for this.
For starters, I looked at research on mergers. There are several studies pointing out that mergers do not lead to better and more affordable care [1-5]. Economies of scale are not feasible according research done by the Technical University of Delft  and large hospitals even have to deal with negative impacts of having become this large. Lack of real integration between the merged hospitals is mentioned as an important factor, as well as the finding that the number of hospitals decrease in the Netherlands, but the number of locations does not. Are these mergers merely cosmetic operations or do they aim for ‘big is beautiful’ or for more power?
Interestingly enough mergers and building new hospitals often go hand-in-hand. In the 23 mergers that took place in the Netherlands some years ago, in 19 of these mergers large scale building projects were undertaken. In the past it was government policy to stimulate merger when building a new hospital. But if hospitals have to deal with financial problems after building a new hospital and the consequences of mergers make the hospital less effective, why do both? Perhaps merger is the means to invest in new facilities or is it the other way around? Are building new facilities a means to be able to collaborate and merge, like some kind of major team building activity?
Informally I talked about these issues with several board members of hospitals. Knowing my engineering background, some of these board members lectured me on the topic: merger is not about efficiency Annelies – and no, your models will not change that – it’s about government or insurance companies pushing us in this direction! It is about politics, about two Boards of Directors that have to work together, there are commercial forces to build new facilities, there are local authorities that take an interest in renewing their hospital, there are personal ambitions to create a large and innovative new hospital. In short, efficiency is not the thing. The external or internal forces however were important drivers for many of these transition plans. They also agreed that bringing in a logistical perspective would take out the emotion that was characteristic for many of these processes. They also explained how, to some extent bring, they tried to bring in these kind of analysis into the discussion in their own hospital.
Having read and heard all this my main research question at that point was how strategic decision making processes, related to hospital transformation, work and to what extent logistical arguments were part of these processes. The first step to answer this question was doing literature research.
 KPMG, ‘Wie doet het met wie in de zorg?’, KPMG Plexus, Editie 2014.
 Weil TP (2010) Hospital consolidations: do they deliver? Physician Exec 36(5): pp 24-27
 Preyra C, Pink G (2006) Scale and scope efficiencies through hospital consolidations. J Health Econ 25(6): pp 1049-1068
 Zepeda, ED, Nyaga GN, Young GJ 2016) Supply chain risk management and hospital inventory: effects of system affiliation. Journal of Operations Management. Doi: 10.1016/j.jom.2016.04.002.
 Kristensens T, Bogetoft P, Pedersen KM (2010) Potential gains from hospital mergers in Denmark. Health Care Manag Sci 13(4): 334-345
 Blank, J.L.T, van Hulst, B. L. , ‘Opereren bij schaalnadelen’, TvOF, jaargang 45, nummer 2, Wim Drees Stichting voor Openbare Financiën, 2013.