Conservative win could kill local NHS shake-up plans

Health managers in the middle of a reconfiguration are in for a sleepless night come the general election.

A moratorium across the board undermines the local capacity of the NHS to best weigh up issues

If they wake up to a Conservative government, plans for reconfigured accident and emergency or maternity services could be out. The Conservatives have said they will “scrap Labour’s plans to cut A&E and maternity services which are not supported by evidence that patient access and care will be improved”.

Conservative leader David Cameron has promised a moratorium on closures and argued that they are often driven by short term policy considerations rather than long term viability. Plans to cut services at the Horton General Hospital in Banbury were driven by the demands of the European working time directive, he claimed. And in 2007, when it looked as if an election would be called within days, he said an incoming Conservative government would stop the closure of A&E at Chase Farm Hospital in north London.

But what will this mean for the NHS over the next six months? We are in a pre-election period with a possible incoming government having very different policies on reconfigurations to those the NHS is working under. Many areas will be reluctant to enter into consultations on changes, for fear government policy will change or they will be caught in a political dogfight on election day.

Relatively few consultations are in play at the moment and a planned one has already been put on hold, probably until after the election. NHS Birmingham East and North had been carrying out pre-consultation work on maternity services at Solihull, which had already attracted attention from shadow health secretary Andrew Lansley.

The primary care trust says the delay is to allow it to develop more options, rather than because of a likely election or political interest. 

But the Conservatives’ proposed moratorium seems to go further and affect reconfigurations that have already been decided and where work may already have started.

Earlier this month Mr Lansley said he would keep maternity services at a hospital in Greater Manchester - despite closure being part of a plan to change services across the whole area. Work has already started on upgrading facilities at other hospitals, which will become super-centres for maternity.

Mr Lansley’s spokesman says the birth rate in Manchester has increased and facilities would be needed at both Fairfield Hospital and the extended unit at the nearby Royal Bolton, but he could not say whether this would also apply to other hospitals in Greater Manchester.

A countrywide moratorium would be temporary while plans for hospital and unit closures were reviewed to ensure local support, especially from GPs, whose commissioning powers could mean units had a viable future, he says. Whether existing decisions were included in this review would be decided later but generally the Conservatives would want to honour existing contracts, he says.

Pressure for change

NHS Confederation policy director Nigel Edwards warns it is not possible to preserve the hospital system in aspic, and that there are lots of pressures for change. He believes many in the NHS would welcome politics being removed from its day to day decision making.

“The logic of the Conservative proposals is there is no direct political interference with reconfiguration decisions and we would hope any moratorium would be short lived, and lead to a rapid review,” he says.

“But even if an independent [NHS management] board has the authority to make difficult operational decisions, [if it makes them] without the support of politicians, both national and local, it will be almost impossible to bring the public with us and make the necessary changes to improve healthcare delivery.”

But the Conservative moratorium is based on the idea that the current process around reconfiguration sometimes produces the wrong answer; David Cameron has referred to short term policy considerations and “tiresome, meddlesome, top-down restructures”. They have also challenged the idea that a large population is needed to support services such as maternity and A&E.

Experts say there is no clear “right population” for a service to cover.

King’s Fund deputy policy director Candace Imison says: “The clinical evidence in terms of critical mass tends to be quite condition specific. There is not a body of evidence that says it is better to deliver services to a population of 500,000 rather than 250,000.”

Royal College of Obstetrics and Gynaecology spokeswoman Maggie Blott says the college’s concern is less about the number of births a unit handles than whether it can provide a safe and sustainable service.

But most decisions are influenced by a number of factors: people’s desire for local, easily accessible services; the need to attract suitable staff - especially junior and middle-grade doctors; the interdependency of different services such as paediatrics and maternity, and the need for diagnostics; and cost - a factor which will be hard to ignore in the next few years.

“We know our reconfiguration is the only way to ensure long term financial viability,” says one manager.

Ms Imison says: “We tend to make these decisions at a local level because it is there we can best weigh up the issues. To put a moratorium across the board seems to undermine the capacity of the local NHS to do this.”

NHS consultation and its ability to make a compelling case for change has improved dramatically over the past few years, she believes. But that is time consuming and costly, and it would be difficult to unpick decisions already made, and has implications for future decisions.

Consultation and public concern have led to changes in reconfiguration proposals - such as the widespread closures in West Sussex which have never materialised.

Decisions overturned

The Independent Reconfiguration Panel offers a fallback in case a “wrong” decision is made. The Horton in Banbury and maternity services in East Sussex have seen decisions overturned, with the importance of patient access put centre stage. Other proposals, such as Chase Farm and Manchester maternity, have been broadly supported by the IRP. 

Greater Manchester children, young people and families network director Leila Williams says the changes there are interlinked, making it impossible to change just one component. But as they have been through the IRP and endorsed by the health secretary she does not expect them to be revisited, and work will continue.

“I would be more than happy to speak with Mr Lansley but more importantly he needs to meet the clinicians who have been the architects of this. They firmly believe that this is the best thing to do - it will save babies’ lives,” she says.

Of course, should an incoming Conservative government adopt a different stance on reconfiguration to the one it professes now it would not be the first time policies have changed when the opposition becomes government.

But they may have raised expectations among supporters that won’t be met, or can only be met at considerable cost.

In Hertfordshire, Hemel Hempstead MP and shadow health minister Mike Penning has said he would reopen the debate about the best site for the area’s main acute hospital. Many millions have already been spent preparing the ground for this to be in Watford.

In Maidstone the Conservative candidate has been running a campaign to stop the move of consultant led maternity services to Pembury - even though this had been agreed years ago and is reflected in the design of a new hospital being built.

Is a Conservative government really likely to hold up reconfigurations which are so far advanced? One manager in a trust in the middle of a reconfiguration says: “If you have the diggers booked, you are probably okay. But if you are still in mid consultation you are at risk.”