Beyond Hub-and-Spoke: The territorial hub as a public health architecture for integrated care.

OBJECTIVES: The Hub-and-Spoke model has long provided a credible architecture for healthcare networks by concentrating high-complexity care within tertiary centers while organizing lower-intensity services around them. This article examines why its rigid interpretation is increasingly inadequate and proposes the Territorial Hub as the missing organizational layer between tertiary expertise and community-based care. STUDY DESIGN: Conceptual policy analysis. METHODS: Hub-and-Spoke arrangements were critically examined alongside district and place-based systems, integrated delivery networks, accountable care organizations and primary-care-led models, focusing on clinical governance, territorial coordination, inter-hub relationships, public health functions, community participation, workforce capacity and transferability. RESULTS: The Territorial Hub is defined as the organizational evolution of the first-level hospital. It assumes vertical responsibility for coordinating Community Houses, Community Hospitals, district services, home care, outpatient services and territorial professionals, while maintaining a horizontal, structured and bidirectional relationship with the Hospital Hub. The Hospital Hub concentrates on high-complexity care, research, education, innovation and the production and updating of clinical standards; the Territorial Hub translates these competencies into locally governed pathways, ensures continuity, manages complexity compatible with local resources and activates timely escalation towards advanced specialist care. CONCLUSIONS: The Hospital Hub-Territorial Hub architecture preserves necessary centralization while overcoming the passive notion of the spoke. Its implementation requires shared governance, explicit safety boundaries, adequate workforce capacity, community participation and evaluation through clinical, organizational and public health outcomes.