A list is circulating - despite Department of Health denials - of 18 trusts that have been deemed unviable in their present form and on which strategic health authorities will be acting. There will probably be few surprises in the names and no surprise that major restructuring of acute services is coming - the government has been flagging it up for the best part of a year.

A list is circulating - despite Department of Health denials - of 18 trusts that have been deemed unviable in their present form and on which strategic health authorities will be acting. There will probably be few surprises in the names and no surprise that major restructuring of acute services is coming - the government has been flagging it up for the best part of a year.

As our main feature outlines this week (see page 20), successful reconfiguration consultations have some things in common. First, faits accomplis do not tend to accomplish anything, except resentment - the experience of Cornwall and Isles of Scilly primary care trust is instructive in the way it began consulting without firm plans and with an independent review panel in charge (with the very independent Professor Nick Bosanquet in the chair).

Second, clinicians should not be 'brought on board' but be driving proposals from the beginning. Trusts not confident enough to do that will only pay an even heavier price later on. Third, do not shy away from the emotion that restructuring provokes - match passion with passion.

A lot can be done locally, but some factors in successful restructuring are created centrally.

A re-engagement with professional bodies is needed. Next week's Royal College of Nursing congress will be notable for the lack of boos and catcalls that were directed last year at the health secretary - because this time she has not been invited (news, page 7). This is a sensible holding position by pragmatic new general secretary Peter Carter, but he believes the RCN is forming more sophisticated relationships with ministers. The quality of those will be tested when this wave of restructuring takes effect and inevitable job losses occur.

It will need all of Mr Carter's considerable experience and diplomacy to bring the membership with him.