Can light-touch Lansley really avoid the toughest decisions?

The health secretary still remains deeply suspicious of what he calls “top-down structural reconfigurations”. This was the reason, he said, that he placed a moratorium on hospital reconfigurations in London and not “because I wanted to avoid difficult decisions”.

He talked disparagingly of “pet reconfiguration projects that have always been around” but have little clinical credibility or support.

He was also dismissive of the idea that it is necessary to make large scale changes to deliver costs savings. “Many of these reconfigurations have numbers written against them that have never been demonstrated to be deliverable,” he said.

Finally, he took umbrage at the view driving many proposed mergers, that trusts must be of a certain size to survive. Mr Lansley cited East Grinstead’s Queen Victoria Foundation Trust as “not a big trust, but a very successful and well run one”.

The health secretary places his faith in the “four tests” which are designed to ensure any redesign is backed by evidence and clinical support. He claims the tests have led to considerable progress in hospital reconfiguration since 2010.

The engagement with clinicians – especially GP commissioners – that the tests have created has smoothed the progress of some changes. But they do not appear to have had a huge impact on the nature of those changes. The proposals halted by the London moratorium are more or less proceeding as planned, albeit with a timetable now challenged by delay.

But is it any wonder that clinical commissioners have not yet had time to develop their own plans – they, after all, have plenty else to focus on.

Mr Lansley claims clinical commissioning groups have “stepped up” much faster than expected, but he also challenges the view that service design changes need to take years.

He acknowledges that to hit the £18bn savings target major savings from service redesign need to be delivered from April 2013. However, he says the new CCG-driven system will do away with the “rather long-winded” processes which, for example, he claims led to the reconfiguration of stroke services in London taking five years.

He is also placing considerable faith in the “redesign of community services” and other areas where “you can shift things quite quickly”, citing the recent reduction of GP referrals and the slowing of emergency demand.

Running between the lines of Mr Lansley’s dislike of “macho” mergers or closures and his championing of rapidly delivered small scale solutions is the hope that it will reduce the amount of political input needed to see contentious reconfigurations through.

However, the idea there will be less political involvement in deciding the fate of hospitals was greeted with laughter at HSJ’s recent roundtable on the NHS provider sector. As much as Mr Lansley might hope otherwise, many experienced NHS leaders believe change on a sufficient scale cannot be delivered without some political capital having to be expended. CCGs and health and wellbeing boards will not always agree, for example.

Mr Lansley is right to challenge the idea that the problems facing NHS hospitals can all be answered by closures and mergers. But in his heart of hearts, he knows there are some high-profile and contentious reconfiguration decisions on which he will have to make the final call – and on which his claim as the first health secretary of modern times not to duck the tough choices will be most severely tested.