Editorial Thursday 29 September 2011: Will The Appleby Hypothesis (MB>MC) decide the next election?

A new research study into viability-challenged NHS hospitals by MHP Health Mandate policy and communications agency offers a political 'heat map', by correlating these trusts with marginal constituencies.

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The MHP research concludes that "21 struggling NHS trusts will be located in marginal constituencies at the next election following a review of constituency boundaries. Of these, 12 are located in ‘super-marginals’ with a notional majority of less than 1,000 after proposed boundary changes come into effect".

It also shows that nationally, hospitals yet to achieve Foundation Trust status are in 13 constituencies with a notional Conservative majority; nine with a notional Labour majority; and five with a notional Liberal Democrat majority.

The research points out that "both the Conservatives and Labour could also be beneficiaries of local rows about closures, with the 11 marginals being targets for the Conservatives and 13 for Labour".

It suggests that seven of these 21 trusts have been identified by the DH as being 'at risk' due to a PFI funding scheme - Barking, Havering and Redbridge; North Cumbria; West Middlesex; Mid-Yorkshire; Walsall; North Bristol; and Royal National Orthopaedic Hospital [not yet signed off].

This talk of marginals reminded me of the Kings Fund chief economist, iridescent Professor John Appleby's proposal that a guide to good health economic decision-making can be defined in just five characters: MB>MC.

Translated into human language, MB>MC means that the marginal benefit of a decision exceeds the marginal cost.

The Kidderminster Effect and the politician's syllogism
Dr Richard Taylor's Kidderminster Effect still cast a shadow as long as a ballot box over NHS reconfigurations.

Yesterday, we discussed the NHS tradition of dealing effectively with organisations that need to change or close - which has broadly been to kick the problem deep into the long grass and hope money arrives to sort it all out in time.

There is no more money coming. This means that we must refer ourselves for guidance to the first line of the Yes, Minister politican's syllogism: "Something must be done".

(We must also beware the completion of the syllogism: "This is something. Therefore this must be done".)

There is a politics-shaped gap in the policy logic of the NHS as reimagined by Health Secretary Andrew Lansley (saviour, liberator). It is around the notion that NHS cuts and closures can be nothing to do with the Secretary Of State For Health.

As well as being fiercely dogmatic to his reform vision, Our Saviour And Liberator is (to his credit) an idealist. There is little reasonable doubt that he truly believes that such decisions should be made locally and led by clinicians. In an ideal world, that would be the case.

Alas for Mr Lansley, we start from where we are. The NHS is political because of its funding mechanism. Cuts and closures are political. That is how the Great British Public perceive it.

Mr Lansley will no doubt try to make some political capital out of the avoidance of difficult issues at these trusts under New Labour in economically-expansionary times, when it would have been viable to double-run alternative, more community-based services.

This is unlikely to rescue him from the fact that these closures look set to happen on his Government's watch and to be attributed (possibly wrongly) to his policies.

This sort of thing happens when you make yourself a hostage to fortune by signing a pledge card to oppose any cutbacks to Chase Farm A&E, as Mr Lansley did.

A farewell to top-down
It is striking to note that DH director of the poisoned QIPP chalice Jim Easton told the HSJ Forum North that the DH are considering a national campaign to promote reconfiguration.

Easton argued "the zeitgeist is right" for "assertively, confidently setting out a bold national vision for how we should change healthcare for us and our future generations ...  should we set out a vision for the change we want, to provide cover support and context for the changes that you’re leading?".

The problem for this approach is, as Easton also noted, that "we’re very conscious of the ‘top-down’ accusation". Quite.

The Lansley plans have discredited centrally-planned top-down approaches, forcing the needed London stroke reconfiguration to jump through 'policy-ically correct' hoops before it could go ahead.

A national initiative is going to be needed. The case must be made that the marginal cost of keeping open full services at these trust exceeds the marginal benefit gained, and that care really is better delivered in other settings - for reasons of both cost and quality.

The slight problem is that in The Appleby Hypothesis, the marginal in question is health economic - rather than electoral and political.

Electorally and politically, the electoral and political marginal cost will be tantamount to handing a loaded weapon to you political opponents; standing still; and hoping that they miss.

It's also going to be against the whole zeitgeist of liberating the NHS.