20 October 2006
The DoH claims that 'reconfiguration' of NHS services is all about improving clinical care. Critics says it's just to balance the books. Either way there are widespread protests against hospital mergers and closures – and HM Opposition is cashing in. Lyn Whitfield reports
One Saturday last month, a headmaster dressed as a fine lady on a pantomime horse led 3,000 people around the streets of Banbury to protest about proposed changes to services at the local Horton Hospital. The 'lady' and the 'horse' provided some distinctive local colour. But the sight of people demonstrating against hospital cuts, closures and changes has become a familiar one in towns and cities across England.
In September alone, tens of thousands of people took to the streets. From Plymouth to Grantham, from Eastbourne to Nottingham, they turned out to protest against changes in their local NHS services. In August, no fewer than 27,000 people marched through Hayle in Cornwall against possible hospital and ward closures.
Despite this, the new chief executive of the NHS, David Nicholson, has made it clear that the pace of reform, and therefore of 'reconfiguration', is likely to increase. He is reported to be expecting about 60 such reconfigurations in the near future, including changes to some of the most cherished of NHS services: accident and emergency, paediatrics and maternity. 'We are going to have to tackle some of these big patient issues,' he said in a recent interview. 'Undoubtedly, there will be tough decisions to be made.'
Reconfiguration has been a hot topic of conversation at the top of the Department of Health since the spring. First, there was the row over leaked e-mails about government 'heat maps', showing where planned reconfigurations are causing unrest – and resurrecting fears of Kidderminster-style election defeats. The Conservatives claimed these were being used to avoid cuts in marginal seats.
And there has been plenty of public activity as well. In July, Andrew Cash was appointed director general of provider development at the Department of Health, with a brief to drive trusts towards foundation status and 'bring about a coherent reconfiguration programme'. Over the summer, Nicholson's immediate predecessor, Sir Ian Carruthers, made a point of telling managers that nervous ministers would no longer block difficult decisions.
Even so, there is no grand 'plan' for hospital closures (though a number of people interviewed for this article said it would be nice if there were). Instead, change is coming for three reasons that can be hard to untangle on the ground: financial crises, long-standing pressures on smaller hospitals and (possibly) an emerging idea of what NHS services should look like in the future.
Or, as Nigel Edwards, policy director of the NHS Confederation, puts it, reconfiguration is in the news 'because pressures we all know about can't be ignored any longer. That, and the money.'
The latest figures from the DoH show that the NHS in England is projecting a surplus of £18m for the end of the current financial year, with the gross deficit down from about £1.2bn to £883m. But this fragile improvement in financial balance has been won at a high price.
Indeed, some of the local protests have been a straightforward reaction to the steps taken by trusts to get back into the black. Last month's rally in Plymouth, for example, was organised by unions concerned about plans to close up to 60 beds and shed up to 400 posts to tackle a £25m projected deficit.
A spokesman for Plymouth Hospitals Trust stresses that it is modernising services at the same time. It is, for example, creating a day surgery admissions lounge that will reduce its beds requirement. But its focus is financial balance.
Some of the other protests have been triggered by plans to address deep-seated pressures on smaller hospitals that would exist whatever the financial situation. These include the drive to improve the quality and safety of NHS services, which has fed into increasing clinical specialisation, and the impact of the European Working Time Directive. In 2004, when the directive was applied to junior doctors for the first time, a 'crisis' in hospital services was widely predicted. This was averted by new ways of running hospitals at night, devising new shift patterns and creating some new roles for clinical staff.
But the directive will pinch further in 2009, when doctors' working hours, including the time they spend 'on call', must be reduced to 48. Among other things, this will make it more difficult, and expensive, to run services that require 24-hour cover, including A&E and maternity units.
The interplay of these pressures can be seen in Banbury. Horton Hospital is run by the Oxford Radcliffe Hospitals Trust, which also runs Oxford's teaching hospitals. It has been consulting on how to make its services both safe and sustainable since 2004, and the future of Horton Hospital is just part of this process, says its director of communications, Helen Peggs, who has been heavily involved in the process.
The trust's consultation document makes it clear that the primary drivers for change are the impact of the directive on staffing and on the way doctors are trained and supported. For instance, it says that Horton Hospital's maternity unit, which deals with 1,600 births per year, is 900 births short of what the Royal College of Obstetricians and Gynaecology would require to renew its training accreditation.
And its out-of-hours anaesthetic cover is provided by one trainee anaesthetist, who also covers other specialisms, which 'does not meet the requirements of the clinical negligence scheme for trusts'.
Peggs says: 'To retain obstetrics, we would need a new layer of anaesthetists, and that is just not affordable, even if we could fill unpopular posts.'
In response to these concerns, the trust is proposing to build up Horton's diagnostic, day surgery and emergency services, but to move out-of-hours and specialist services, including consultant-led maternity care, to Oxford. Peggs says this will not necessarily save money, since it will have to invest in a new midwife-led service and other facilities.
However, the health service across Oxfordshire is facing a £33m gap between its funding and its costs and activity this year. As a result, the consultation on Horton Hospital was brought forward to coincide with a bigger consultation on efficiency across the trust. Underlying pressures and financial pressures have become entangled.
The pressures facing small hospitals such as Horton, and the bigger district general hospitals that serve small to medium-sized towns, have been under the microscope for some time. In the late 1990s, a flurry of reports came out of medical bodies arguing that many services would have to migrate to 'superhospitals'.
In 1999, for example, a particularly influential report from the Joint Consultants Committee suggested that superhospitals serving 400,000–500,000 people would be needed to maintain a full range of specialisms and A&E support services, plus the training to go with them. It suggested that where district hospitals serving populations of 200,000–300,000 people remained, they should form 'acute groups' offering more services than a single hospital could manage on its own.
Nobody has ever built a superhospital, although the report's figures turn up regularly in documents supporting reconfiguration around the country. And since then, both managerial and medical organisations have put considerable effort into finding alternatives, or partial alternatives – not least because of the long journey times that regional centres would imply for some patients.
In 2003, the DoH issued a guidance document, Keeping the NHS local, which challenged the 'mind-set' that 'biggest is best' and set out 'new evidence' that 'small can work'. It instructed managers to look at 'whole systems' working when proposing changes and to 'redesign rather than relocate' services. This newer thinking has been seen as good news for local services in general and for community hospitals and midwife-led units in particular. But the recent pronouncements from the DoH/NHS chief executive seem to suggest a reversal in approach.
Jon Skewes, director of employment relations and development at the Royal College of Midwives, says the RCM was very concerned by Nicholson's comments because they implied that women should give birth in consultant-led units in larger centres.
While this debate has been going on, another strand of policy thinking has come into play – how to shift services for long-term and preventable conditions out of hospitals and into communities and homes.
Again, the ideas are not new. But the government has become increasingly interested in them, not least because of the influence of US models of care, such as that developed by Kaiser Permanente in California. The white paper Our health, our care, our say, published in January this year, distils some of this thinking. For local hospitals, this is likely to be a double-edged sword. Campaigners tend to think that the white paper supports popular local services. But the trend is to push more of what they do out into other settings. Health Secretary Patricia Hewitt made it clear, in a recent speech to the Institute for Public Policy Research think-tank, that these services might be run by independent sector providers.
The co-operation that would be required to resolve all these tensions sits oddly with the government's mantra of competition and the financial regime of payment by results, which tends to push work back into hospitals.
But in so far as there is a model emerging, it revolves around what are sometimes called 'gradated services'. Broadly, the idea is that patients should be able to access escalating levels of support, from telemedicine to super-centres dealing with trauma and emergency surgery, via 'polyclinics' and 'locality' hospitals doing routine and minor injuries work.
Interestingly, something very like this triggered last month's protests in Hastings and Eastbourne. Surrey and Sussex Strategic Health Authority probably had the highest debt in the country, £100m, in 2004/05. It has since merged with another SHA to form NHS South East Coast. Just before the merger took place, the authority issued a Fit for the future consultation, which discussed the pressures on services, including the need to focus on prevention and chronic disease management and to shift these services closer to people's homes. Local press coverage has focused on the 'threat' to local hospitals posed by its proposals to create new emergency, surgery and maternity centres at just a few locations (which means 'downgrading' others to locality status).
It has paid much less attention to the other innovations. But Dr Amit Bhargava, a GP in Crawley, says the area is trying to create a new model of care, influenced by Kaiser Permanente, in which acute is split from community care but staff work flexibly between the two.
Major change, he says, will save money. And he believes that ministers have grasped that. 'I think this is happening now because yes, it is hard to handle now, but every year it is put off, it will get harder,' he says.
He adds, though, that a 'consistent narrative' about change needs to be developed – and that politicians will have to resist the temptation to interfere with local decision-making when the going gets tough.
Individual reconfigurations, then, are a response to a range of pressures – but it does not follow that they are a response to the right ones. Skewes has no doubt that many changes to maternity services are being driven by simple 'retrenchment'. But he argues that centralisation might not be safer, if women have to travel further, and might not be cheaper, if it pushes intervention rates up even further.
Ian Gilmore, president of the Royal College of Physicians, says: 'We have been saying for years that there needs to be a reorganisation of services. We have also been saying that clinicians need to be engaged early, to make sure that changes are driven by what is best for patients, and not just by finances. Change might not be cheaper.'
He is also concerned that while some of the ideas behind a shift to community and primary care services are sound, 'the investment and the infrastructure needed has not yet happened'. Indeed, a sceptic might ask if they will ever be developed – and, if so, whether they won't disappear at the first sign of financial stress, as is happening with some mental health services.
The idea that politics can be kept out of change, meanwhile, is wishful thinking. The Conservative Party has launched a campaign called 'Stop Brown's cuts'. Tory leader David Cameron, who told his party conference that his priorities could be 'summed up in three letters – NHS', has already been supporting Banbury's Horton Hospital as a local MP. And shadow health minister Andrew Lansley has pledged greater independence for the NHS.
It would be harder to play political games if the public bought into local changes, which is why Nicholson has also been sending out the message that proper consultation will pay dividends. Since Keeping the NHS local, there have been considerable changes in the way the NHS consults. Health communities, rather than individual bodies, have tended to issue consultation documents, and these usually start with general issues, rather than specific proposals for change.
Oxford Radcliffe Hospitals Trust is somewhere towards the end of this process, while NHS South East Coast is right at the start of it.
But the massive wave of NHS protest marches suggests it is not working. George Parish, the Banbury town councillor leading the Horton Action Group to save the hospital, has sat through countless review meetings. He still believes the changes are financially driven and represent a simple loss of services for local people.
'We want the trust to rotate staff through the different hospitals to address the concerns about safety and working hours,' he says. 'But the trust has this £33m overspend and it does not want to know.'
Similarly, Michael Foster, Labour MP for Hastings, said recently that Fit for the future had simply 'generated negative publicity' and 'raised local concerns'. He also uttered what might be an inconvenient truth. 'It is not possible to close local hospitals. People would rather have a slightly inferior service than have to travel.'
Expect more demonstrations soon.
Public Finance is hosting a round table on health finance and reform in London on October 25 in association with Deloitte
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