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Guest editorial Tuesday August 10 2010: To the barricades - re-reconfiguration (again)

Irwin Brown of the Socialist Health Association looks at re-reconfiguration (again)

We had a phase in our local NHS when cuts were feared, and we saw campaigns about keeping open facilities that were not going to be shut (just in case).  There was even a hard-fought campaign preventing moving a GP surgery from old inaccessible premises a few hundred yards down the road to better, bigger, modern premises.  

A year ago, there was an air of concern in the DH that reconfiguration (changing and just possibly shutting things) was taking far too long; was too bureaucratic; and was too likely to be derailed by well-meaning but ignorant locals - or worse, by malign councillors on Scrutiny Committees.

Then we get an election and everyone everywhere is against anything which is opposed by anyone.  About one-third of elected MPs had actively campaigned against some kind of change (real or imagined) in their patch.

The new Coalition government stops all top-down closures, especially of A&E and maternity facilities; never once referring to the significant body of evidence about risk, thresholds and clinical safety.

The Burns unit
The closure of an “A&E Department” in Newark (of all places) gets on telly and is halted, with a visit from Health Minister Simon Burns as a punishment for suggesting that totally misleading A&E signs are taken down.  The grand scheme for London goes into the wastebasket and the SHA chair resigns.

This turns out to cause some unintended problems - in that the cunning plan that is QIPP (or QIPPR as it now is) which will cut expenditure by £X zillion, sought of depends on shutting things and reorganising services, in London to the tune of around £5 billion.

Unhelpful metropolitan clinicians started pointing out that far from being top-down, the changes to major trauma, stroke and PPCI which came under attack were in fact clinically led and examples of using good clinical evidence. Some early implementation of changes already demonstrated health gains.

So we have to have reconfiguration without anything being seen to be reconfigured, and with the guarantee that if there is any local uprising, then the blame can be attributed to local GPs who have a high 'being-liked' rating.  This is clearly sound, since we all know how GPs always look broadly and take a wholly independent and strategic view.

The Dear Comrades letter from Sir David setting out the new approach is a masterpiece.  It sets out a process that is even more bureaucratic, time-consuming and opaque, with everything having to be tested by a surviving quango - the amusingly-named Co-operation (?) and Competition Panel. Signatures must be collected and boxes ticked.

The new process relies heavily on SHAs, PCTs and on OSCs: all three-letter acronyms soon to be no more.  The really clever bit is that it is largely free of anything that could be objectively tested.

In one wonderful part, it sets out how local people can only challenge the decision taken by the bureaucrats who have consulted them if they have a body of evidence which somehow they overlooked when making their case during the consultation.

Everyone has accepted for years that the distribution of NHS facilities and the configuration of services grew organically, through neither rational planning nor even a market.  Urban settings may have two A&E (real A&E) departments within walking distance.

Some clinical specialities (Oxford Radcliffe) do need high patient thresholds to be safe.  Some services could be better provided outside hospitals.  Some patients in beds in Community Hospitals could be in cheaper but no less appropriate social care facilities. And so on.

Pleasing all of the people all of the time
Changes can be made which benefit patients, which improve quality and which do save scarce resources.  But you have to change some tangible things and close some things down to bring these benefits and for sure someone, somewhere will be ready to oppose every step.  Some PCTs were actually starting to get good at engagement and consultation, but knew that you can’t please all the people all the time.
Still by October all the schemes put on hold and ridiculed as examples of typical top-down bureaucratic interference will probably all be started up again.