Writing in today's Daily Telegraph, Health Secretary Andrew Lansley outlines his four criteria for NHS service change.
He writes of the key tests, "First, there must be clarity about the clinical evidence base underpinning the proposals. Second, they must have the support of the GP commissioners involved. Third, they must genuinely promote choice for their patients. Fourth, the process must have genuinely engaged the public, patients and local authorities".
It is good to have these so clearly set down for the NHS, local government, clinicians and communities to consider. There are, however, problems with three of these four criteria.
Objective or subjective?
Only the second of these four is empirically measurable. The first, third and fourth are all opinions.
On the first - clarity about the evidence base - Lansley knows well that the classic NHS trick, when faced with bad or unwelcome news, is to dispute the evidence. He does it himself in the fourth paragraph of his article, describing "closures, or reconfigurations, of local services (are) based on disputed or flawed evidence".
So we need to know who will decide on the evidence. For the decision to have credibility, it will need to be clinicians. This is a bit of a challenge for the NHS, since clinicians are not much engaged in management.
The third category - that of genuinely promoting choice - offers interesting challenges. DH patient surveys find that about half of respondents recall being offered choice when appropriate. This certainly suggests that choice is not being taken up as it might. It is unclear from these surveys whether GP forgetfulness or wilful refusal to promote choice is the issue, or whether it is patients' recollections.
Whatever the driver, there appears to be an issue.
The recent Civitas review of market reforms in the NHS concluded from a review of the literature that "in practice, the uptake of choice policy is not yet widely realised, and degree of implementation varies geographically".
The question is about how one could quantify the genuineness of promoting choice. It is unlikely that many people will openly admit they do not promote choice, but any who do will be low-hanging fruit.
Yet it may be that a significant number of people genuinely prefer to choose their local provider. The reasons may be cultural, demographic, educational - or just force of habit.
The forthcoming research on patient choice from the Kings Fund will have some interesting thoughts about the issues of choice.
If genuine promotion of choice is challenging to assess, then Lansley's final key criteria - that "process must have genuinely engaged the public, patients and local authorities" - is a monumental cultural challenge to an NHS that normally only engages with its community when it wants to shut something. Small wonder that public engagement is generally feared and dreaded by NHS managers. It can prove controversial, despite the fact that it is a legal duty.
NHS bodies must consult the Overview and Scrutiny Committee of the Local Authority (Reg 4 and 4A Local Authority (Overview & Scrutiny Committees Health Scrutiny Functions) Regulations 2002), and involve or consult service users and potential service users (section 242 NHS Act 2006). Foundation trusts must consult OSCs and Monitor if the change alters their terms of authorisation.
It is a very good idea that the NHS should engage with its community and users. Yet the scandalous history of patient and public involvement and engagement (Community Health Councils killed off for being too independent; the Commission for Public and Patient Involvement in Health and Patients Forums an utter waste of time; LINks fast-heading the same way) does not inspire immense confidence.
Changing and closing services should not be a lottery. One objective, empirically-measurable test out of four is not great odds.