The public often suspects that the financial crisis is the real cause of hospital closures, even when other reasons are given. The NHS has found it virtually impossible to proceed with closing, or even downgrading, local hospital services. Even when the technical argument has been strong, the local voice - emotional and sometimes irrational - has been very powerful and has generally been successful.
A recent report suggested that up to 20 hospitals in the UK NHS must close in order to save the system from financial meltdown. It has attracted considerable attention, in part, because it comes from three influential and varying perspectives - managers (NHS Confederation), doctors (Academy of Medical Royal Colleges) and patients (National Voice).
Continued operation of the NHS in its current form will lead to a £54 billion deficit in 2022 and as a publicly funded service it is simply not sustainable, they say. By explicitly stating that potential hospital closures will be caused by financial difficulties, it’s both blunt and refreshing.
Decisions to close hospitals have typically been described more generally as “service reconfiguration” and there are many, and often competing, driving forces behind changes. These include advances in technology, an ageing population, patient safety and efficiency savings, all of which tend to push the idea of larger hospitals that have more specialists and operate as centres of excellence. Improvements in cancer care and stroke services are good examples of this, but it’s more controversial to suggest that Accident and Emergency (A&E) departments might follow suit.
Who thinks what?
We studied three large-scale reconfigurations in detail - each one very different and representing urban, rural and inner-city areas - and found that where you stand depends on who you are. The patient safety, clinical excellence argument is usually made by doctors, while the taxpayer efficiency argument is usually made by internal non-clinical groups such as health managers.
We also found it’s very difficult to find good quality data to establish exactly how reconfiguration affects specific services, that is, whether they have improved or not. This suggests that many reconfiguration plans are developed to deal with a serious concern for the local health community, such as failing hospital care, but not followed through fully.
A political hot potato
Changing hospital care is more a political process. A report from the IPPR think tank said: “Hospital change is not a technical, managerial problem.”
The majority of NHS managers will acknowledge that where they have advocated radical change or rationalisation of services they have been blocked by local politicians, who often lead campaigns to save a local service. Recent opposition has included foreign secretary William Hague and work and pensions secretary Iain Duncan Smith.
NHS chief Sir David Nicholson, due to retire next year, captured this nicely in a recent speech. He said politicians were servants to “the tyranny of the electoral cycle”.
In many ways this is understandable. Professional politicians have re-election as a priority and standing with the local voter is a viable position to take. It reminds me of the political television satire, Yes Minister, where a civil servant describes a minister’s decision as courageous when what he means is political suicide.
Predictably, everyone is saying patients (read the public) will be involved fully from the very start. And alongside the argument for 20 hospitals to close is also reassurance that more will be invested in GP surgeries, health centres and social care.
Politicians who don’t want to advocate closures often propose local public engagement as an alternative. So much so that all government policy towards reconfiguration appears to be enhanced public involvement and consultation. But it’s very optimistic to assume that more involvement will be educational and will lead to a smooth acceptance of changes to services.
But the “20 closures” proposal may seem appropriate in the context of the NHS having to save £20 billion in its costs. However, finding more flexible, creative and innovative uses of resources might produce a more palatable solution.
And there may yet be some much more radical solutions - beyond closing hospitals - which don’t surface because too much of what we already have is taken as given, not just for the public but for the government.
Why not abandon the commissioning process - the introduction of CCGs which put GPs in charge of NHS funds - and its associated costs? Virtually no other country employs this process where different people are responsible for allocating funds. And why not abandon the idea of a market in healthcare? It has not worked and where it is, the predominant model has seen costs of health provision increase rapidly.
We should have a system where hospitals collaborate in local communities and services are shared and allocated appropriately. The increasing ageing population will need many more social care and non-acute health beds, ie not in hospitals, so why not make smaller hospitals collaborators of bigger specialist acute units?
What the government shouldn’t do is launch a campaign to persuade the public that despite their basic instincts, closing their local hospital will be good for them. We should instead invest and create alternative high quality services so that the alternative is in place before any nearby hospital is closed and the alternative is so much better - convenient, good quality and appropriate for what the local community needs.