On paper, West Hertfordshire health authority's current public consultation on the reconfiguration of services appears impressive.
When consultation ends this month there will have been some 250 meetings, including workshops, seminars and conferences, since it began almost a year ago.
Public reaction to a range of options put forward during a four-month discussion period helped the HA to whittle down proposals to two choices for the future of local healthcare. The HA is keen to be seen to be open to public involvement.
Critics see it differently, describing the long drawn-out talks as a ruse designed to disguise an inevitable financial decision to centralise acute services.
Scepticism about the limited impact of public consultation on the decision- making process is hardly peculiar to West Hertfordshire.
But given the HA's tangible efforts to create a dialogue with the public, why does the mistrust linger on?
Suspicion arose in March when the two acute hospital trusts in West Hertfordshire were named by former shadow health secretary John Maples as earmarked for merger or closure. A taskforce to 'increase collaboration' between the trusts was set up shortly afterwards.
In May, the HA published its consultation document, outlining its preferred option of replacing the two acute hospitals with one, to be built on a greenfield site and backed by community hospitals. The next working day, the two existing acute trusts announced plans to merge.
Local unions and hospital groups greeted the merger proposal as evidence that West Hertfordshire was heading straight for its favoured option, regardless of public preference.
An HA spokesperson admits the timing of the two announcements stretched credulity.
'Any change during what has been a long process can mean people see it as a sign that the major decisions have already been made. But we discussed this and decided that decisions like these could not be avoided as time moved on,' she says.
The HA's second option would keep open the accident and emergency departments in Hemel Hempstead and Watford, the biggest towns in the HA area.
But the price would be a package of cuts, split between community and hospital services and bearing hardest on services for elderly people. Women's and paediatric healthcare would also be centralised.
Veteran hospital campaigner Zena Bullmore, a member of South West Hertfordshire community health council, accuses the HA of being disingenuous.
'How long could an A&E department survive without those back-up services? The two options amounted to the same thing - centralisation and the loss of acute local services. The HA claimed to offer the public a choice. In fact, it seemed more of a threat.'
HA chair Professor Roy Swanston defends the plans as proof that public opinion has been heeded.
'What we are saying is, if this is what you want you can have it - but we are spelling out what the consequences would be if we were to choose this road.'
HA officers claim clinical support for their preferred option which, they say, shows that money is not the only motive for change. That view is challenged in a joint response commissioned by five local councils from Dr Allyson Pollock, senior lecturer in public health sciences at St George's Hospital Medical School, south London. She says the proposals are financially driven and not based on health needs.
Last year, National Audit Office accounts put West Hertfordshire's deficit at 15.85m - 5 per cent of its income. Unaudited figures for 1997-98 show an increase to 16.23m.
Dr Pollock says the consultation document is confused, lacking in needs analysis, badly informed and contrary to national evidence of increasing acute need. She describes the plans as a 'crude attempt' to reduce the HA's capital charges, currently costing 20.4m a year.
In any case, she argues, the overall deficit would be increased by either option since both would reduce the HA's income.
The local councils, which have rejected both options, are now threatening to go to judicial review if the HA proceeds with its plans.
The proposal for a greenfield site is also in trouble. The HA wants to use a site owned by Hertfordshire county council in Langleybury, which is equidistant from Hemel Hempstead and Watford. But councillors are overwhelmingly opposed to the sale and council staff were due to be moved to the site this week.
Ms Bullmore says: 'People thought Langleybury was a red herring. I think it was more than that. It was an attempt to get the public to accept the concept of an out-of-town acute hospital as the least worst option.
'Once the public had signed up to the idea - or at least stopped fighting it - then West Hertfordshire would be free to build the new hospital wherever it wanted.'
The HA insists that is not the case. It has made 'strenuous efforts' to release facts to the public as they emerge.
But local campaigners say that for consultation to be meaningful, sharing information needs to be followed by sharing the decision making, too.
Other HAs have found - for example, by using citizens' juries - that when offered full information and invited to make choices, people often reach the same conclusions as health managers.
If West Hertfordshire had followed this route, would it be facing less suspicion now?