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New NHS system threatens a tsunami of hospital mergers

June Hautot, the pensioner who confronted Andrew Lansley outside Downing Street last month, is a veteran of hospital closure campaigns.

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.

Readers' comments (14)

  • How and from where are we going to find the resources (time and money) to keep any form of routine care going in the face of all this?

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  • And I repeat my question posted on a similar subject elsewhere...

    'And where is the proven link between mergers and improvements in patient outcomes?'

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  • Interesting concept of creating massive providers and breaking up commissioners into smaller units. It does not sound like a fair fight will be had and the larger may well ignore the smaller (as they do now).

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  • Didin't we have large NHS entities 20 years ago. I think they were called health authorities? What happened to local involvement? Also, how will concept of the market work in the face of what could become geographic monoplies?

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  • Actually, as a newcomer to the NHS it always struck me as odd that there were no regional or national hospital chains, as there are in most other industries.

    I dont think this has anything to do with, as the editorial suggests, the new system. If anything the new system will lead to less of these things as there is no real strategic system leader in the new world.

    No. These mergers are mainly driven by lower financial settlements played out through tariff reductions.

    The one thing they have in their favour is at least being able to be developed at run by the organisations themselves, compared to the commissioning changes which are subject to a poorly run pseudo national process.

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  • Who says the driver of mergers is efficiency. It is more likely to be cost and control of the 'market'. Leviathan FT's will tell CCG's what they can and cant have and patients had better keep their figures crossed. Organisational Darwinism when intelligent design is needed!

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  • I remember St James Balham... Gateway to the south, I worked there
    As for South London Hospital Clapham.... I was born there
    I must be past my sell by date then!

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  • NHS management continue to delude themselves that big mergers and or shared services are the answer to the Nicholson challenge. Look at South London healthcare Trust (as 1 of many examples) - has the merger of troubled trusts led to an improvement or worsening of the situation.

    The problem in the NHS acute sector is around poor process as a consequence of poor management, poorly aligned incentives, low staff morale etc. the NHS should focus on the root cause problems, not look for a false silver bullet in mergers like this

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  • The whole point of all these mergers and "efficiency drives" is they have nothing whatsoever to do with being more efficient or improving care for patients, they are there to dismantle the NHS completely, drive through private care, even though private insurers are losing money hand over fist and have stopped funding new hospital projects and patient care. This is policy based on ideology from the 1980's. Jane Hautot is one of many, like myself who remembers local hospitals that were shut during the Thatcher years, South London Hospital for Women & Children was one, another was St James' in Balham, along with the Garrett Anderson, a small cottage hospital my mother spent some time in after a difficult pregnancy with my youngest brother. All gone in the name of "efficiency and offering more patient choice". Sound familiar? It ought to be. This bunch of second hand car dealers are the same as they were then and they're just finishing the job that was started then. When are we going to wake up and protest about it? When we all have to have private health cover or before then????

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  • Market forces have NO PLACE in healthcare. Not if we are truly providing healthcare free at the point of use.

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