Editorial Monday 28 January 2013: The clinical confusion and democratic deficit in healthcare reconfiguration

On Saturday, I saw that Enfield North MP Nick de Bois (a Conservative) had published an open letter on his website in response to Sir Bruce Keogh's Guardian interview asking politicians not to attack plans for NHS provider reconfiguration.

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Today I noticed that Andrew Lansley's former health special adviser Bill Morgan, now back at communications firm MHP Health Mandate had written his own response to this.

All offer thoughtful perspectives on this wicked problem of provider reconfiguration.

I may already have bored regular readers with re-promoting something I wrote back in December about the unacknowledged practical issues around reconfiguration.

As you all know, I am not a clinician, and so can't write meaningfully about the clinical case.

But Sir Bruce Keogh is. A good one, who drove the cardiac surgeons' publication of performance data after the Bristol Royal Infirmary paediatric surgery scandal that led to the Kennedy Inquiry.

Sir Bruce contended to The Guardian that the risk is that reconfiguration refuseniks "perpetuate mediocrity ... I really need the help of our political colleagues at times to step above their local interests and think of the other interests of the NHS.

"Unless we can get to that place where people look at the greater good, which is sometimes in conflict with local interests, then professional, personal and political interests will conspire to perpetuate mediocrity and inhibit the pursuit of excellence to the detriment of our NHS and ultimately our patients ... Anyone who doesn't embrace change in a position of power, whether clinician or politician, should be held accountable for the consequences of the NHS failing to deliver the quality of care expected".

Nick de Bois is pretty unhappy about the plans to close Chase Farm's A&E, as you might well be if you'd campaigned as he did on an anti-closure platform and had Andrew Lansley sign a hands off Chase Farm A&E pledge card.

And even more so if PM David Cameron had announced in 2007, "What I would say to Gordon Brown is if you call an election on 1 November we'll stop the closure of services at this hospital on 2 November".

Nor was this an issue to which de Bois came out of mere electoral opportunism: he had founded the 'Hands Off Our Hospital campaign in 2004. He was elected to Parliament for Enfield North in 2010.

de Bois writes to Keogh, "NHS London adopted a flawed consultation process with the public, often carefully selected individuals meeting in central London hotels far removed from the locality the hospital served. The NHS failed to be transparent and consistent in their arguments over the years leading to mistrust and lack of confidence in the administrative leadership of NHS London,Enfield PCT and the acute hospital board of Chase Farm, Barnet and North Middlesex.

"No wonder in 2010 I was elected on a mandate to defend Chase Farm against the downgrade of the A&E unit in particular. My concern is that you choose to dismiss the electoral mandate so easily and with such contempt underlines exactly why the public do not trust the management of the NHS as they fail to engage or listen to the concerns of informed local patients and residents.

"If re-configuration is the route to clinical excellence in hospitals why were the medical front line profession not taking the lead in arguing for these changes? Since 2003 in Enfield I don't recall many GPs or clinical leads from the acute hospitals publicly arguing for the changes. I hope that on reflection you will realise it is not politicians who are just concerned about some of the proposals for change but the public that elected the MPs. That is why I and my residents will continue to fight these proposals.

"That to date both this government and the last have chosen to ignore the views of patients and residents despite their repeated pledge not to do so is deeply regrettable".

Bill Morgan suggests in his blog that to simplify matters, the financial arguments for reconfiguration should be set aside and only the clinical ones used.

Morgan finds common cause with Team Keogh that "the clinical arguments are complicated, counter-intuitive, and – sometimes – they seem to be unfair", and with Team de Bois that "clinical arguments hardly ever stick is because they are rarely clear-cut ... the NHS designs them to be hard to win ... (and) they are often badly made by the NHS. If the clinical case for change is nuanced, or being challenged by other clinicians, then the NHS all too often does not seek to strengthen the clinical case, as they should do, but instead simply adds other ‘arguments’ which only serve to undermine the original one.

"From my personal experience, I cannot immediately recall any reconfiguration proposal backed by sound clinical reasons which didn’t also have in its consultation documents a line somewhere about the reconfiguration also being necessary for ‘financial reasons’. Why say this, if a reconfiguration is happening for clinical reasons?"

Closing time
To put it mildly, experience suggests that the general public don't like the closure of NHS services. This may be because we live in a time of increasing suspicion of experts and politicians alike.

Or it may be because, as Morgan points out, there is not very frequently a black-and-white case. Clinical opinions, like clinical practices, vary quite widely, and are probably not always backed by up-to-date empirical evidence.

Empirical evidence of the actual effects of reconfiguration is also not always collected and published.

Clinicians are also human beings, and so can be loss-averse if the status quo suits them pretty well.

It ain't just what you do, it's the way that you do it
There is also a well-established tradition in NHS management of deciding in advance what the outcome of a reconfiguration is going to be, and then designing your public consultation in the way to maximise your chance of getting the responses you want, while also doing just enough of the process of consultation to get you by in the likely event of a judicial review.

The case for major change in NHS provision has yet to be made to the public in a clear, comprehensible way.

Thus far, the background noise is one of a government protesting its financial "healing", or rebalancing, which is not happening as planned because of low-to-no economic growth.

Cuts and tax increases have begun to bite, but their teeth have deeper to sink. The UK economy's slide back towards a probable triple-dip recession, and the slip in value of the pound (which may help exports slightly) and likely loss of triple-A credit rating will raise the cost of government borrowing while importing more inflation. We're all in this together.

I say reconfiguration, you hear cuts
All this means that many people may listen to talk of 'the need to reconfigure NHS provision', and hear 'cuts and closures'.

That may prove highly toxic for a coalition government that has not exactly taken the country with them on health policy.

It creates fascinating challenges for the opposition, too. The temptation to run a 'save the NHS' campaign could be immense, conflating perhaps-necessary changes with cuts.

But I'm reasonably reassured by the presence on the opposition front bench of Liz Kendall , who was special adviser to Patricia Hewitt, the last Health Secretary to make serious efforts to reconfigure provider capacity in the NHS. Kendall is not stupid, and saw this close-up from the inside in 2006-7.

Labour could offer a cross-party approach on provider reconfiguration, which could make them look like a grown-up, statesmanlike opposition.

And a true cynic might suggest that if this were properly done and communicated, it could reduce the political wriggle-room for the coalition government to avoid acting.