There are trends towards centralising hospital care within the NHS, for many excellent reasons. Yet this has a disproportionate impact upon those patients who live at a distance from their hospital, and this impact has not been well reported or researched, but studies have demonstrated that the utilisation of services is inversely related to the distance of the patient from the hospital; so-called 'distance decay'. This article examines the trend and describes the reasons for it, and the impact on those living in remote and rural communities. It argues that health service planning needs to be patient centred, and points out that, although providing services to rural communities is more expensive than that for urban populations, a balance needs to be struck between cost-effectiveness and the provision of accessible and equitable services for all of our patients. It argues for a debate to help define where that balance point should be, and makes certain recommendations. This debate is especially important, because the professions urgently need to decide how to respond to the UK Department of Health document 'Keeping the NHS Local -- a new direction of travel'.