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Editor’s blog Monday 24 May 2010: Lansley's reconfiguration inspirations - Pollyanna, Pangloss and Micawber

Further to this recent post pointing out that only one of Secretary Of State For Health The Rt Hon Andrew Lansley CBE MP’s four tests for service review is empricially measurable, it was interesting to pick up this DH press release.

The DH release says that Lansley “outlined new, strengthened criteria that he expects decisions on NHS service changes to meet.  They must
- focus on improving patient outcomes;
- consider patient choice;
- have support from GP commissioners; and
- be based on sound clinical evidence”

London’s NHS reconfiguration should, Lansley added, see the “top-down, one-size fits all approach … replaced with the devolution of responsibility to clinicians and the public, with an improved focus on quality.
“It will be centred on a sound evidence base, support from GP commissioners and strengthened arrangements for public and patient engagement, including local authorities”.

These revised criteria are slightly less odd. Yet his ‘Gang Of Four’ are still slogans – the opposite of each is ridiculous.

Lansley may quite reasonably passionately dislike and disagree with the proposed Healthcare For London approach, but it is ridiculous to suggest that they:
- focused on worsening patient outcomes
- ignored patient choice
- had no support from GP commissioners, and
- were based on unsound clinical evidence

More specifically, it is ridiculous to suggest that proposals can ignore patient choice, which now has some limited statutory status (though not legally enforceable) under the NHS Constitution.

The question of support from GP commissioners is an interesting one. The Health Select Committee report into commissioninig points out that decommissioning is not in great evidence. It cited the Audit Commission’s November 2009 report into productivity and efficiency in the NHS, which concluded that “PCTs made little or no in-road in 2008-09 to transferring care from hospitals into the community or in dampening demand, either in terms of investment or activity”.

It also noted HSJ’s 2007 survey finding that the majority of PCTs had failed to decommission any services.

So does Lansley simply believe that GPs will be more active, participative, hands-on commissioners and decommissioners than PCTs have proved (despite the fact that DH surveys of PBC steadily find that a quarter of respondents basically disagree with the policy)?

Such a belief takes some faith. It is ‘a big ask’ (in the popular vernacular).

If you believe that all London’s – or the whole NHS in England’s - service provision is already as it should be, and there are simply £20 billion of efficiency savings sitting around the NHS waiting for somebody to notice them over the next few years, you may be comforted.

Miss Pollyanna, meet Mr Pangloss and Mr Micawber
Such optimism is usually the province of the inhabitants of the pages of classic literature: that we are playing “the glad game”; that “all is for the best in this best of all possible worlds”; and that “something will turn up”.

However, Mr Lansley and colleagues would do well to remember Micawber’s other great dictum – the Micawber Principle - "Annual income twenty pounds, annual expenditure nineteen pounds nineteen and six, result happiness. Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery."

And as clinicians, managers and politicians all know well, you can always question the evidence if you don’t like it.