Why a health service redesign hit the rocks

Earlier this month one of the most ambitious reconfiguration processes ever started outside London hit the buffers. West Sussex primary care trust put on hold the final part of the Fit for the Future process, which three years ago cast uncertainty over services across Surrey and Sussex.

Merger talks between two of the trusts, Worthing and Southlands Hospitals trust and Royal West Sussex trust in Chichester, could open the way to foundation trust status and keeping emergency surgery and possibly consultant-led maternity services at both sites.

Opponents now hope the reconfiguration process will be buried and a clinically led solution developed. Mark Signy, a cardiologist at Worthing, says: "I suspect Fit for the Future would not be resurrected unless the merger talks fail. That's a bit of a loaded gun to hold over both trusts."

The analytical approach to what services were needed and could be afforded has yielded little of the changes originally expected (see below). It has, however, convulsed public opinion with rallies, petitions and torch-lit vigils capturing the headlines.

What are the lessons for other health economies that might be thinking about similar exercises?

The first is that consultation costs. The PCTs and strategic health authority spent more than£2m on the process. The bill for West Sussex PCT alone is likely to be more than£1.5m. It is also a lengthy process, especially if stakeholders are to be involved in extensive "pre-consultation engagement".

The process started shortly after the last election. But if an Independent Reconfiguration Panel referral for West Sussex goes ahead - health secretary Alan Johnson has asked for it to be put on hold - a final decision may not be made until within months of the next general election. The length of the process makes it very hard to separate reconfiguration from politics, even though Labour has few seats to lose in this area.

Winners and losers

Conservative MP for Chichester Andrew Tyrie points out that Brighton has been the big winner in the process while St Richard's Hospital, part of Royal West Sussex trust, has been under threat - despite providing high quality care at a low price. "Some have pointed out that Brighton and Hove contain marginal seats. I can't possibly comment," he says.

NHS Confederation policy director Nigel Edwards says some reconfigurations can take up to 20 years to come about. In some cases, it has taken several consultations before changes have actually happened.

This length of time means that some of the original drivers for change can disappear and others will grow in prominence. When Fit for the Future started, the NHS in that area was in financial trouble. Saving money was crucial - the January 2006 "first steps" document says the NHS in Surrey and Sussex had an underlying deficit of£100m a year - but since then the finances of the area have been transformed.

This means there has been more emphasis on the other argument for change: ensuring services at acute hospitals are clinically sustainable. Central to this - and to selling it to the public - was clinical engagement, very much in line with June's next stage review.

But opponents were quick to argue that clinicians had not been adequately involved and it was easy to find doctors who would argue that patient care would suffer from the proposals.

Worthing and Southlands medical director Michael Rymer says: "There was a feeling, particularly in the early stages, that the clinical engagement was fairly constrained along very defined lines. It was not a blank piece of paper. It was: these things will have to happen, how are you going to do it?"

Imaginative solutions

The process was also seen as pitching hospital against hospital, which may have prevented some imaginative solutions emerging. Now clinicians in Worthing and Chichester are identifying some areas where services can be streamlined and emergency surgery potentially preserved at both sites.

The SHA, NHS South East Coast, says the fundamental issues around service models have not changed and highlights achieving sufficient patient throughput to achieve a critical mass, while also achieving better local accessibility of services.

But some of the details of thinking on service models may have subtly shifted. The Independent Reconfiguration Panel threw out the plans to centralise maternity services in East Sussex, questioning the safety of long transfer times, emphasising accessibility and choice and saying alternative models of medical staffing could provide better consultant cover. This seems to undermine many of the arguments for fewer but larger maternity units, certainly in areas where travel time and access are key issues.

The panel's report is thought to have been on the mind of PCT managers in West Sussex as they pondered what to do with their proposals. Worthing and Chichester are 21 miles apart while Hastings and Eastbourne - the subjects of the East Sussex review - were only 17 miles from each other.

The development of a new option to keep accident and emergency services at both St Richard's and Worthing over the last year - the model that has now been referred to the panel - also showed that innovative thinking could bring forward more acceptable solutions.

Co-design success

Surrey PCT, which originally faced huge opposition but did not have to press ahead with A&E or maternity closures, feels its approach of co-design, involving clinicians and the public in developing models from first principles, worked.

Its proposals were more modest but, unlike other areas, it did not end up with a public consultation, having won the support of the overview and scrutiny committee. It points out this is a learning process for the NHS, as it is far from the "tell and sell" approach often used, but is in line with post-Darzi thinking.

The SHA says PCTs will be using the connection they have made with local communities and that it believes people in the region now have a much better understanding of the issues and are more engaged in discussions.

"In that sense we have influenced public perceptions and opinions. Where there is less consensus is in terms of how this translates into local decisions and how service changes will benefit people," it says.

SHA chief executive Candy Morris adds: "We have created innovative approaches to patient, public and stakeholder engagement that will serve us well as we continue the journey of change and improvement."

Brian Hughes, Fit for the Future programme director at West Sussex PCT, says: "We have developed better relationships both with and outside the NHS about how to make services clinically sustainable, deliverable and affordable not just now but well into the future."

Naked ambition

But was the whole programme too ambitious? Trying to achieve change in a piecemeal fashion may have been more attractive but, says Mr Edwards, it would have been difficult as so many services are interdependent.

In many ways, the Fit for the Future process was a textbook approach, but it meant that for a long time there was everything to play for - few services appeared safe. In fact, as early as March 2006 the SHA was looking at a number of scenarios that involved "losing" acute hospitals in Surrey, East Sussex and West Sussex, and presentations at the time mentioned the "public and political acceptability" as important factors.

The breadth of the review did allow opponents to gain public support and exploit a persistent belief that everything had been decided and consultation was a fake. In Kent, where the process was introduced in late 2006, there was suspicion from the start: one pressure group called it "a Trojan horse hiding a sinister agenda which has already been decided". In fact the process in Kent led to relatively few changes - and none that were particularly controversial - but the SHA says the process "offered an important affirmation of the existing models".

The Kent process did not go far enough to raise much public concern but in Surrey and Sussex normally staid residents seemed prepared to take to the barricades in defence of their local hospital.

West Sussex county council leader Henry Smith (Con) says: "I suspect that the PCTs were not expecting that sort of opposition and organisation. I think that was a little bit naive. You can make detailed clinical arguments about where A&E should be... but people still get concerned if they don't get emergency facilities nearby.

"There was a complete disconnection between the public understanding of having acute services close by and the rather theoretical clinical arguments."

West Sussex will not be the last area to have to manage that tension.

THE LONG ROAD TO CHANGE

Reconfiguring services first reared its head in Surrey and Sussex three years ago when the SHA - now part of NHS South East Coast - started to look at sustainability of services.

In January 2006 the SHA produced a discussion document which said that five or six centres were needed for emergency surgery and medicine, six for obstetrics and six for paediatrics to give the "ideal size for clinical quality". This would mean a substantial cut in the number of centres providing these services and, although the document made it clear this needed to be reconciled with local geography, it was to be a rallying call for opposition.

By the autumn of that year the emerging options were becoming clear: Surrey to lose an A&E, substantial cuts in A&E and other services in West Sussex, and East Sussex to lose one maternity unit - although A&E there was unexpectedly reprieved.

But things changed. In Surrey an improving financial situation meant that by mid-2007 the proposals were about improving clinical outcomes and no longer about "major changes to acute hospitals".

In West Sussex, suggestions from clinicians led to a revised model which kept more services at each of the threatened hospitals but was still referred to the Independent Reconfiguration Panel.

Only in East Sussex were unchanged proposals pushed ahead - and this summer the centralisation of maternity services was thrown out by the panel.