During the summer our HSJ Local service has been reporting on plans to reduce hospital workforces. This week we reveal Aintree University Hospital Foundation Trust’s decision to remove 200 posts during each of the next three years.

August also saw Princess Alexandra Hospital Trust in Essex declare its intention to cut 250 posts in 2011-12, while Blackpool Teaching Hospitals Foundation Trust is looking for a reduction of 325 this year and 675 by March 2014.

The most worrying aspect of many workforce reduction plans – dramatic though some of these cuts are – is that they are being made with little idea of what the future will bring and are also, therefore, sometimes seasoned with a fair degree of wishful thinking.

For example, ask most trust chief executives whether reducing Agenda for Change increment payments must play a part in achieving efficiency goals and they answer, “of course”.

Yet not one trust has moved to take such a step. With unions warming up members for potential industrial action over pension reform, trusts know the first mover is likely to become the focus of NHS staff fury.

Despite figures such as NHS deputy chief executive David Flory stating that growth in the pay bill “will bust the system”, the government has no intention of making another rod for its back by issuing a national edict. And so we continue on. National and local leaders agreeing something must happen and planning on the basis that it will, but both too scared to take action.

But this is by far from the only uncertainty over the size and nature of the hospital workforce. Of even greater importance is the shape of hospital services and how they will be paid for.

The Cooperation and Competition Panel’s decision that Basingstoke and North Hampshire Foundation Trust can merge with Winchester and Eastleigh Trust without contravening competition guidelines is a welcome step towards clarity in one area of reconfiguration. However, elsewhere the realignment of NHS services along lines which are meant to deliver approximately half the £20bn savings target is moving with a slowness which reflects both the confused commissioning landscape and the difficulty of the task. In theory, to deliver the savings target, most reconfiguration plans would have to be in place by the year-end. That seems unlikely.

In those places where reconfiguration is happening, it is as likely to be driven by providers as by commissioners. In many of those cases, the reconfigurations are, understandably, being influenced as much by concerns over the financial stability of providers as by developing patient need.

Again, fear of the spotlight is a powerful incentive. If financial – and the resulting clinical – problems are inevitable, best to delay them as long as possible in the hope that they can be fixed quietly while some other troubled organisation reaps the whirlwind of being the first to fail. 

When it comes to paying for hospital services, the move to reward quality rather than activity is showing signs of moving from the “jaw, jaw” to the “war, war” stage. Clinicians are kicking up a fuss over what they believe may be the impact on clinical priorities, while trusts that fear it will reduce revenue are likely to follow suit.

All of this is part of the inevitably painful birth of a wickedly complicated new payments system, which has much to recommend it in theory. However, the uncertainty it generates – like that over reconfiguration or pay reform – means trusts will be forced to focus on “controllables” as they seek to deliver efficiency goals. Number one on that list of “controllables” is likely to be further cuts to the NHS workforce.