New NHS system threatens a tsunami of hospital mergers

She has been opposing closures since the early 1980s, mentioning in an interview St James’s, St Benedict’s and Clapham Women’s hospitals – all in south London.

Who now remembers these hospitals or the arguments made for or against shutting them? The point being there have been hospital reconfigurations for as long as there has been an NHS.

Nevertheless, according to the NHS’s leading historian Geoffrey Rivett, the scale of change being proposed during the QIPP ice age is unprecedented.

Mr Rivett’s views are reinforced by the findings of the first HSJ/Capsticks Barometer survey of acute and specialist trust chief executives. Two thirds of the 65 chief executives who responded said they were involved in mergers and/or the acquisitions or transfer of services.

The poster child for this tsunami of mergers is the £1bn giant being formed in east London, but the key merger trend may turn out to be the linking up of smaller equals. Medway Foundation Trust’s takeover of Dartford and Gravesham should create an organisation big enough to survive, as will the combination of Poole and Bournemouth.

Even where mergers are not taking place there is steady disaggregation of services between hospitals, often to private and voluntary providers. In fact, the Barometer’s clearest message is of a divide between winners and losers. Even where smaller trusts are not being gobbled up many face a steady reduction in services.

The efficiency drive has combined with the movement of all trusts to foundation status to spark this great rationalisation.

The boards of many acutes around the £100m-turnover mark had hoped they could make it as independent foundation trusts. Very few have been allowed to try and none without community services. Staff costs, tariff reductions and shifting resources to primary care all conspire against the optimists at the smaller trusts.

Many of the Barometer’s respondents complain about the growing demands of the FT application process. The bad news for them is that, in the wake of problems at Morecambe Bay and, possibly, in anticipation of the conclusions of the Francis inquiry into Mid Staffordshire Foundation Trust, that assessment is going to get even tougher. It is also increasingly clear there are a significant number of smaller foundation trusts that face a very challenging future and would not pass assessment were they applying now.

Monitor – and the Department of Health – will wish to avoid de-authorisation at all costs and this is very likely to encourage the regulator to increase its intervention in struggling foundations. Again, mergers are likely to be the answer proposed.

The DH – directly through strategic health authorities and indirectly with Monitor – is overseeing the reshaping of the acute sector. But we will soon be living in a different world, with the DH exercising influence through an annual mandate.

The scale and speed of change requires careful oversight and sometimes rapid reaction. In the future different elements of this change will be in the hands of Monitor (still struggling with its new regulatory role), the NHS Commissioning Board, clinical commissioning groups, the Care Quality Commission, health and wellbeing boards and the Trust Development Authority.

These bodies all have requirements to cooperate, but also to maintain independence. How and when they should work together is still to be determined and tested. The future of England’s hospitals depends on an effective solution being found by the end of the year.