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Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare. CMR was managing director of UCLPartners until August 2021. NJF is a non-executive director of Whittington Health NHS Trust and trustee of Health Services Research UK. She is a non-executive director of the COVID-19 Bereaved Families for Justice and has legal representation in the UK Covid-19 Inquiry. GAF is a non-executive director of NICE board, CSL Behring consultancy stroke trial design. He is a trustee of the Picker Institute; NIHR strategy board member; Health Services Research UK trustee; Accelerated Access Collaborative board member; chair of Pfizer/Bristol Myers Squibb independent atrial fibrillation detection improvement grants panel; chair of Cardiovascular Healthcare Systems strategic forum (Novartis funded) and Bristol Myers Squibb/PwC Life Sciences 2030 Cancer Moonshot Roundtable. He is chief executive of the Oxford academic health science network, which has multiple joint working agreements and medical education grants with industry partners that are contracts with Oxford University Hospitals NHS Trust.

Competing Interests: Competing interests: MI-K is the National Clinical Lead for Deterioration and Sepsis at NHS England/NHS Improvement. NJF led the evaluation of virtual wards in England.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare that NJF is an NIHR senior investigator and was in part supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Barts Health NHS Trust. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Objective: To investigate whether centralisation of acute stroke services in two metropolitan areas of England was associated with changes in mortality and length of hospital stay., Design: Analysis of difference-in-differences between regions with patient level data from the hospital episode statistics database linked to mortality data supplied by the Office for National Statistics., Setting: Acute stroke services in Greater Manchester and London, England., Participants: 258,915 patients with stroke living in urban areas and admitted to hospital in January 2008 to March 2012., Interventions: "Hub and spoke" model for acute stroke care. In London hyperacute care was provided to all patients with stroke. In Greater Manchester hyperacute care was provided to patients presenting within four hours of developing symptoms of stroke., Main Outcome Measures: Mortality from any cause and at any place at 3, 30, and 90 days after hospital admission; length of hospital stay., Results: In London there was a significant decline in risk adjusted mortality at 3, 30, and 90 days after admission. At 90 days the absolute reduction was -1.1% (95% confidence interval -2.1 to -0.1; relative reduction 5%), indicating 168 fewer deaths (95% confidence interval 19 to 316) during the 21 month period after reconfiguration in London. In both areas there was a significant decline in risk adjusted length of hospital stay: -2.0 days in Greater Manchester (95% confidence interval -2.8 to -1.2; 9%) and -1.4 days in London (-2.3 to -0.5; 7%). Reductions in mortality and length of hospital stay were largely seen among patients with ischaemic stroke., Conclusions: A centralised model of acute stroke care, in which hyperacute care is provided to all patients with stroke across an entire metropolitan area, can reduce mortality and length of hospital stay., (© Morris et al 2014.)