'If the Michael Porter view won converts in this country it would mark a major and highly controversial change in the specialist infrastructure.'

If it hasn't been certain before, it is now - payment by results will profoundly destabilise the specialist hospital sector. Previously, children's hospital trusts have banded together to voice their protests. But as we report this week, they have been joined by five specialist orthopaedic hospitals.

From their point of view, the position is clear - the complex care in which they specialise is not fairly reflected in the tariff, making their entire business unviable. They say that once central government transitional aid ends in 2008, the situation will pose 'a serious threat to patients'.

The concern is understandable. But is it likely that these sorts of care will either revert to the block contracts of the past or be subject to a radically different level of tariff? Or rather, does it mean that the specialist landscape needs to change, with trusts restructuring their cost base, concentrating on the truly specialist work. For example, it is the view of some involved in the process by which applicant foundation trusts are assessed that children's trusts may need to transfer some non-specialist work to general trusts, or even partner with them formally.

That will be very difficult. NHS leaders recently attended a private event to hear US business guru Michael Porter talk about his new book on redesigning healthcare. He argues that centralisation works and that the US in particular should have far fewer specialist acute centres. If that view won converts in this country it would mark a major and highly controversial change in the specialist infrastructure.

Closure and merger is difficult enough at the best of times, but the powerful public awareness that many of these trusts enjoy may make it a step too far.

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