Editorial Monday 17 December 2012: The reconfiguration game
For some time, I've been meaning to write about the challenges facing provider reconfiguration.
There are a few significant ones, really.
Click here for details of 'I'm a Health Secretary: Get Me Out Of Here!', the new issue of subscription-based Health Policy Intelligence.
The first is that most people are not health policy geeks, and as a result have absolutely no idea there is even any need to change how we provide healthcare.
Within the health policy industry, there seems to be a significant body of opinion which agrees that small may well not be beautiful for provision of certain services (maternity and A&E).
It also seems agreed that the case for specialising some care in fewer, bigger centres, as with the stroke reconfiguration in London, looks pretty good.
Beyond healthpolicyland, I get the impression from my non-policy-geek friends and acquaintances that nobody has the slightest clue this issue is coming.
This is not because nobody has tried. To their considerable credit, both Mike Farrar of the NHS Confederation and Professor Chris Ham of the Kings Fund have used their public platform to try to start getting this message out there.
I don't think their efforts were bad: the opposite. It just doesn't seem to have started a national conversation of the kind that's certainly required.
This may, of course, have something to do with the fact that we don't pay our taxes to the NHS Confederation or the Kings Fund. We pay them to HMRC, which is the Accounts Payable department of government - which we elect.
Looking to elected politicians for leadership on this is tricky. By and large, these people want to get or stay elected, and have mostly formed the view that they will get Kidderminstered if they propose or support closures of unviable providers.
It's my party and I'll cry wolf if I want to
This isn't a party political point, by the way.
Labour Cabinet ministers forgot about collective responsibility when Patricia Hewitt was trying to shut stuff, and pitched up on picket lines when services in their constituencies were threatened - even a former health minister like Hazel Blears and former health secretary like Dr John Reid.
Latterly, erstwhile Lib Dem health minister Paul 'Who?' Burstow maintained an ongoing 'Save Our St Helier' section on his website in protest at reconfiguration plans for St Helier hospital throughout his time in post.
It was curious that Andrew Lansley (saviour, liberator) - who knew a great deal about micro-level policy and operational detail, and thus of the need to change provision - both campaigned against NHS cuts in opposition and enforced the promised moratorium on reconfigurations on taking office. This was an area where the tactical change of mind in office might have worked wonders.
It would require the wisdom of Solomon and the tolerance of angels for Labour basically not to do the same back - unless Liz Kendall's memory of what faced Hewitt (to whom she was special advisor) wins out against the more obvious tack.
Bring me my P45 of burning gold
Serious reconfiguration is going to lead to clinicians currently in hospital posts losing their jobs or finding them change beyond recognition. And even in healthpolicyland, there seems to be very little acknowledgement of this.
Let's say you're a consultant in a small DGH in a specialism the hospital will probably lose if there's provider reconfiguration. You've probably already got to the peak of your career: if you were going all the way, you'd be running a CCG - just kidding! You'd be in a teaching hospital in a big fashionable city.
If the provider reconfigurations happen, bang goes your little empire. You'll have to work differently, and possibly for less money - certainly for less job security. The laws of supply and demand will exist in clinical workforce as they do elsewhere.
If the provider reconfiguration don't happen, then you'll continue to have power and status, and thus quite significant impact on your fiefdom. Big fish, albeit smallish pond. If a chief executive comes along with silly notions you don't like, you can easily work with colleagues to get rid of them: we all know those ropes.
You're a local clinical leader, who influences your colleagues. What do the incentives suggest that you should do?
Will local government love foregoing revenue?
One of the bits of the public sector hard hit by the Coalition Government's choice to protect NHS funding in real terms (nearly) was local government.
Local NHS providers pay business rates, I was astonished to discover thanks to the formidable PCT Cassander on Twitter.
Some of this reconfiguration will cause providers to shrink. Somer may even close.
So is there a perverse incentive for cash-strapped local authorities, as regards backing or opposing reconfigurations?
Mmmm. There just might be.
Oh yes, and there is no more money
Until such point as we discover The Magical Money Tree Where Cash Grows For Free, there is no more money to start providing the care for frail elderly people in community settings or support in their own - let alone even getting to prevention of avoidable admission.
Cumulative prospect theory
Cumulative prospect theory reminds us that we usually frame potentially uncertain change with reference to the status quo of how things are (or how we know them) now. Loss aversion, and all that.
So to get us over that hump, it's going to need unprecedented, dazzlingly-executed communication and dialogue about the case for a really huge reform of the NHS, that most people don't know is coming and that many in providers will not want.