MACHIAVELLI CONTINUES HIS BLUFFER'S GUIDE TO MANAGING THE NHS

One of the truly awful duties of the NHS manager is to undertake public consultation. The first point to consider is whether a consultation is actually necessary.

The key organisation to worry about is the community health council. do not worry about the staff.What are they going to do? Go on strike? If they do, they will do your dirty work for you. do not forget: for the time being anyway, CHCs' sole power relates to consultations - the ability to refer the whole matter to the minister.

If you do not hold a consultation exercise, even this limited delay will be precluded. The deciding factor is usually whether your proposals represent a 'significant change in the pattern of provision of services'. What does this mean? Anything you want it to mean, more or less. What, for example, is 'significant'? The CHC, of course, will claim that anything is significant. It may even demand to be consulted on the details of your new corporate logo.

Let's say you want to close a small, much loved (by all but you), outlying hospital. This is not significant because the place represents less than 10 per cent of your available beds/staff/expenditure/treatment episodes.

Unfortunately, this argument rarely works, so you'll have to do the consultation anyway.

Unless - and it is a big 'unless' - you can claim you have to close it for emergency reasons.

An emergency can be anything: impending financial disaster, shortage of staff or - best of all - a health and safety issue. You can probably find all these justifications fairly easily. Get the estates department to crawl all over the building looking for asbestos or unfortunate bio-chemical dumps.

See if the structure is sound.Was lead-based paint used in redecoration? Is the radiological protection up to scratch? Does the fire alarm system work? Arrange for the fire officer to visit and find all the fire doors wedged open.

Get something dangerous to collapse (oldfashioned radiators can be encouraged to fall off walls fairly easily) and call in the Health and Safety Executive.

The point is, if It is an emergency you can close the hospital without further ado. You'll still have to have a consultation at some point, but who can object once the place has been empty for two years, has been vandalised, and all the equipment re-used elsewhere? This is the route of choice because it enables you to get what you want as quickly as possible.

However, let us take the worst-case scenario and you have to go through with the damned charade. Your first step is to take the CHC chair into your confidence. Explain that the closure is absolutely essential if your new mega-hospital rebuild is to get off the ground, or that much more difficult 'choices'may have to be made instead of its closure. You might hint that your A&E may not be safe if St Comfortable's is not terminated instanta.

CHC chairs like this sort of backstairs intrigue, but they will not want to be at the forefront of support. That doesn't matter. All you want is for them not to oppose outright.

On the basis that once played, the opposition card is spent, you can easily buy them off with promises of further formal involvement in the project elaboration process. What does that mean? Nothing, but it gets you off the hook.

Lest you think this is fanciful: the closure of one of London's largest hospitals was achieved happily in precisely this fashion.

Now to your consultation document. It will be expected to be precise, cogent and understandable. Needless to say, my loyal readers would expect the opposite - and they would be right. The actual document will trawl backwards through the history of the NHS over scores of pages. Numerous and meaningless decision-support matrices (when you make up a table proving your option is not only best but the only practicable solution) must be generated to support the plan; an entirely fictional sensitivity analysis will do likewise. Finally, your proposal must be shrouded in ill defined promises of further investment and service development, so long as the closure is the only thing which is clearly stated. Then send it out on as restricted a basis as possible.

You ignore all opposing responses as they will never include costed and measured alternatives. They can't, because you hold all the raw data. You then sorrowfully close the place down, pack off the old biddies to a private nursing home and have a party for your staff and supporters.