'Reconfiguration may do more harm than good'

Ten years ago the word on every manager’s lips was “capacity”. I remember one senior regional manager saying: “We are desperately short of capacity.” Fast-forward through the last decade and the word is now “reconfiguration”, in other words too much capacity.

The conversation runs: “We have always had too many hospitals – anyway we can do so much more in the community, and this one should now close.”

As Nigel Edwards of the King’s Fund memorably remarked, some of these meetings are like shipwrecked and starving sailors looking round the lifeboat with the strongest sizing up the weakest as the first to be eaten.

But can the NHS really have gone from not enough to too much capacity in 10 years? If true, the investment in staff and hospital buildings that reflected many local decisions and aspirations should indeed have been much better spent on new service models.

It also implies the service will make a dramatic leap in efficiency, if only large-scale reconfiguration can be brought about.

You will have guessed by now I am sceptical about “reconfiguration” being the silver bullet it is seen as. Yes, services will always need to change and beds will need to close to make cash-releasing savings. Even during the last decade of investment, acute bed numbers fell steadily each year. But I find implausible the idea the NHS will only stay in the black and provide good quality services if significant numbers of hospitals close or don’t offer full district general hospital services.

An obvious issue is the time this would take. My own experience of reconfiguration started 20 years ago as part of a grand pan-London plan. The new hospital is only just opening and the original idea of closing one was long since shelved. Indeed, experience suggests the costs of closing a hospital is the same as the price of building a new one – and there just isn’t the capital for much of that.

Convincing the public

Reconfiguration arguments assume hospitals will be much more efficient or that we will meet demand differently, including making supply-induced demand disappear.

If the first is true, trusts targeted for reconfiguration should have much higher reference costs. This does not seem to be the case. If anything, higher reference costs are associated with higher allocations, not with hospitals targeted for closure. It would be good to have some outstanding examples of efficiency that reconfigured services could strive to achieve.

If the demand arguments were true, I’d expect to see some primary care trusts or trusts consistently forging ahead with successful approaches to emergency admissions and chronic disease management, based on different patterns of services. But that isn’t the case – or at least not on the scale that would clearly result in fewer hospitals.

It would help if there were successful alternative models of care and working to scale that result in greater efficiency and fewer hospitals. There are frequently quoted foreign examples and statistics. We have spent more than a decade sending study groups to look at them, without, so far as I can see, making any progress towards matching them.

This brings me to convincing the public about reconfiguration. People seem willing in theory to take the medicine of austerity (see the latest polls) but less willing to swallow it in practice when personally affected (see the public sector pensions dispute). Reconfiguration will increasingly mean “cuts”, not quality improvements, unless alternative services are up and running and their impact is plain.

The last time we had major reconfigurations because patients did not need to be in hospital was when the old psychiatric hospitals closed. It was not quick, although new service models were available. Care in the community got a bad name because of perceived weaknesses in new services. It needed regional long-term funding strategies that recognised double running costs. Services were better, but not cheaper.

So I would stop the easy talk of reconfiguration being the way forward. Instead, we should focus on the following.

First, make sure the money available to the NHS is in the right place to begin with. Reconfiguration is often linked to financially challenged trusts. But, it surely cannot be just coincidence that nearly every health economy in outer London is in difficulty.

Second, make the maximum bread and butter efficiency gains. NHS Evidence has validated QIPP case studies that would achieve £1.6bn of savings if taken up by only half of NHS organisations. And the recent Nuffield Trust report Can NHS Hospitals do More With Less? presents the evidence on how acute and mental health trusts have achieved cost savings and improved efficiency.

Third, centralise where there is a clear quality case for doing so. And finally, introducing new service models for some defined services where there are already powerful examples – like stroke services in London.