What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

We’ll back you… then overrule you

A chorus of hospital reconfiguration battles has been rising from several parts of England in recent weeks. Those seeking to navigate the coming months and years will be listening carefully.

Developments in Lancashire are particularly concerning.

The back story is that in April, Lancashire Teaching Hospitals Foundation Trust moved to “temporarily” close the accident and emergency unit at Chorley and South Ribble District General Hospital at short notice, citing insufficient doctors to staff rotas.

Shortly after, Simon Stevens seized on the decision to illustrate that the centre would support those making unpopular decisions over service change. “I think that [Lancashire Hospitals chief] Karen Partington made the right decision about what was needed,” he told HSJ. “I know it was tricky, it’s given rise to some controversy, but I think Karen took a responsible set of actions under difficult circumstances.”

This was an example of how national bodies could give “safe harbour” to NHS leaders making such decisions in coming years, the NHS England chief executive said. Many observers thought it was the right call.

The change was opposed, though, by Chorley and South Ribble Clinical Commissioning Group and vehemently so by the very assertive Chorley MP Lindsay Hoyle, alongside other local politicians.

Five months and a change of prime minister later, it appears the national bodies have lost their nerve.

The trust has been told by NHS Improvement to reopen the Chorley A&E part-time in January, despite the regulator acknowledging the “very real risk” involved.

As a signal of whether national NHS and political leaders stand ready to provide the requisite air cover for controversial change, this seems pretty bleak.

The road to reconfiguration?

In the early days of the STP process, it was particularly geared to bringing forward hospital reconfigurations. NHS leaders were strongly encouraged to confront the difficult decisions in their patch – ie: unpopular service consolidations which have long sat on the backburner.

The message has blurred a bit since then: some STPs still feel they are being egged on to centralise; others now report being discouraged, particularly where the political row looks too hard.

Regardless, most STPs can be expected to ultimately follow in the footsteps of the “success regimes” – their older close cousins.

Sixteen months have passed since the three success regimes were kicked off with the instruction to make their health service affordable and functional.

Two of the patches – North Cumbria and Devon – have just begun reconfiguration consultations. Essex has not yet, but something is expected in the near future.

North Cumbria has proposed centralisation of paediatrics, obstetrics and stroke services – while keeping an A&E running at Whitehaven – and taking beds out of some community hospitals; it has met strong political opposition. Proposals from Devon are so far confined to centralising community hospital beds (much less dramatic, but also not being welcomed with open arms).

If STPs are free to propose what they think is needed to close financial gaps (and meet safety requirements, given workforce shortages) then many will – at some stage – reach unpalatable centralisation proposals.

(An interesting parallel debate is about how national quality standards are applied. Often set by royal colleges or similar professional bodies, the disparate range of national guidelines are generally not mandatory but they might feel it to those running the services. It’s often unclear whether recommendations are for an ideal situation, versus what might be good enough if you are trying to keep a good enough A&E going in somewhere like Whitehaven. The issue has been explored by the Academy of Medical Royal Colleges and the Nuffield Trust in relation to rural and small hospitals, referring to ”aspirational rather than non-negotiable” standards. National leaders have sought to pick at this issue, but there’s been nothing decisive.)

High politics and a pipeline

Our understanding of Theresa May and Number 10’s attitude to this wave of reconfiguration on the horizon is she has declared she doesn’t want the NHS to serve her a list of planned hospital closures, along with the implicit message: “more money please, otherwise we dare you to deal with these” (ie: exactly what many thought the STP negotiating strategy was).

It leaves us with a familiar realpolitik: the PM wants the NHS to get on with change, but not any noisy closures. Similarly, you can close things, but only in the unlikely event you can win the public-political-media game.

A wave of reconfiguration proposals is surely still on the way – the question is how it is phased.

Simon Stevens, Jim Mackey and colleagues have been very anxious to prevent STPs getting into the public domain before they have issued their stamp of approval, giving them tight control over the pipeline.

And the timing of STP publication and implementation is still a fog.

We’re told to expect a small-ish first cohort ready to get on with it in the next few weeks. We know a few STPs are ready and itching to serve up their proposals. Some – Devon, Cumbria, Dorset – effectively already have.

Other STPs, despite a desire to show some thinking to a baying public, are not at the point of solid proposals for consultation, and mood music suggests some won’t be finalised until into 2017.

If STPs follow in the mould of the success regimes then many will take 16 months from the word go (about March 2016 for STPs) to public consultation – taking them to summer 2017.

Confusingly, a health minister told the Commons yesterday that all STPs will be published by the end of November.

Is that the sound of STPs returning those “difficult decisions” to the backburner?

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Dave West, senior bureau chief

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