In its final season, "Downton Abbey" captured audiences by exploring a healthcare phenomenon set in rural England 100 years ago — and one still playing out across America today.
The phenomenon is hospital consolidation, and historical period drama "Downton Abbey" tackled it with the same gusto with which it took on the deterioration of class hierarchies, the emergence of the women's liberation movement and many other social issues over six critically acclaimed TV seasons.
At the beginning of the 20th century, hospitals in both England and America were much different places than they are today. They offered basic nursing services to keep patients as comfortable as possible and not much more. These institutions were most typically standalone facilities largely underwritten by local philanthropists.
During this period, modern medicine began to take hold. Sophisticated organizations, often associated with universities and generally in urban areas, began to adopt new 'technologies' like operating rooms, pathology, electrocardiograms, X-rays and others. These advances changed the nature of hospitals and healthcare. Hospitals shifted from warehouses for recovery, and often decline, to early examples of what hospitals became in the late 20th century.
In the same way "Downton Abbey" had asked questions like, "Why is Mr. Carson, the head butler, so eager to perpetuate class roles?" and, "How would Lord Crawley, the conservative patriarch, react to his daughter's liberal political activities?" the show asks:
"Why would a local community reject modern medicine?"
Over the course of "Downton Abbey's" final season, we learn the answer. There is a cost associated with modernizing the local hospital, and it is not primarily economic. The cost is control.
Modernizing the hospital requires the clinical and scale resources of a partner. To capture those benefits, the town's parochial elites, who built the hospital and have overseen its delivery of nursing care for years, would need to cede some of their absolute control over the endeavor. As Maggie Smith's character states, "less control ... is what I consider my duty to resist."
Efficiency, access to treatments, medical staff advancements and other scale benefits are seen as acceptable casualties relative to "diminishing [the board's] own importance." To overcome this resistance to change, "Downton Abbey's" proponents of progress work to frame the argument and place the healthcare of the community above the personal, societal and historic concerns of the few. Maggie Smith's character's group on the hospital board is content exerting its "control" to maintain the status quo. Unfortunately, that status quo places the healthcare of their community at risk.
To counter this, those that recognize the benefits of medical advancement work to reframe the debate. They question whether "local control" should be the goal, or whether the board has a broader mandate than self-perpetuation. This cohort says the primary question is which system is more likely to deliver modern treatment to the local population — not which system is more likely to maintain their historic positions.
The reason "Downton Abbey" enjoyed so much popular success is that the issues the show confronted are as applicable today as they were 100 years ago. The choices today are not between nursing-only facilities and hospitals with X-rays, but the tension between control and scale is very definitely still relevant.
From the Roaring Twenties to the 2010s
We have dedicated our careers to advising hospital boards on transactions. We spend our time in hospital boardrooms across the country addressing the exact issue confronted by "Downton Abbey" — how can hospital boards best meet the healthcare needs of their communities and support the institutions to which they have donated so much time and energy?
Our clients, like the board portrayed on "Downton Abbey," are concerned with how change will impact their communities. They recognize that without scale, things important to them like quality, consistency, outcomes and efficiency can be more than just expensive — they can be illusory.
If the tension 100 years ago was between standalone nursing beds and facilities with X-rays and ORs, the tension today is between standalone hospitals and small systems struggling to make the shift from fee-for-service to population health and organizations with the infrastructure in place to keep patients out of the hospital by driving quality, efficiency and consistency.
What strikes us 4,000 miles away and a century after the "Downton Abbey" story is how human these struggles are. Today's nonprofit hospital boards, typically consisting of very well-meaning volunteers, face the same existential question that their counterparts on "Downton Abbey" and community boards faced after the turn of the last century: How do we best adapt to changing times to ensure the highest quality, most efficient care for the communities we serve?
What we have learned in our work across the country is what "Downton Abbey" so deftly demonstrated in its final season: These decisions are best made through thoughtful spirited debate that is grounded in actionable information and alternatives.
Rex Burgdorfer and Jordan Shields are Vice Presidents at Juniper Advisory, a specialized, independent investment banking firm focused exclusively on providing community hospitals and health systems with advice related to partnerships, affiliations, joint ventures, and a range of M&A strategies. They can be reached at rburgdorfer@juniperadvisory.com and jshields@juniperadvisory.com.
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