Just what the doctor ordered? How should the case for NHS reconfiguration be made?

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Healthwatchers will surely have noted the interview in The Guardian last week in which Sir Bruce Keogh, Medical Director of the NHS, implored local politicians to stop opposing closures – nay, ‘reconfigurations’ – of NHS services. It is a similar message to the one which Sir David Nicholson conveyed at the NHS Confederation last year. Indeed, it is a familiar refrain of NHS leaders.

What many but the most ardent healthwatcher would not have noted, however, was the ‘open letter’ which Nick de Bois – MP for Enfield North (and thus MP for the constituency which includes Chase Farm Hospital) – published on his website in response. In it, he pointed out that the NHS had failed to make the case to the Enfield population for the closure of A&E at Chase Farm Hospital, which helped ensure he was elected on a mandate to campaign against it.

Now, I am neither the MP for Enfield North nor – thank god – the Medical Director of the NHS. But I do recognise and sympathise with both of the arguments they make. In my time as a Special Adviser in the Department of Health, I found myself all-too-often positioned on the faultline between them: you work in a Department which often champions the sectoral interests of the NHS; but you are also acutely conscious that it is your job to intercept and offer alternative advice to the Secretary of State on matters – such as reconfigurations – which have such potential political ramifications. And you sit in meetings with people like Sir Bruce – and understand, acknowledge and agree with their arguments – and then sit in meetings with people like Nick and apologise for having done so.

It is not an easy role to play, but – having played it – I feel that I have some advice to offer both the political world, and the world of the NHS.

‘Reconfigurations’ – a word which is seen as factual to the NHS but as a euphemism to the public – can take place for financial reasons (a hospital, or a health ‘economy’ (ie region), is unsustainable) or clinical reasons (a hospital or service is in danger of becoming unsafe), or both. They are both sides of the same coin, ultimately – a hospital which has fallen over financially is not going to be clinically robust for long, and vice versa. But to make my argument simpler, we will take the finances away.

Thus, in our world without finances, let us imagine that any service changes are happening only for clinical reasons. It is a good assumption to make, because the vast majority of reconfigurations do not tend to be triggered by financial reasons, even if that is what the majority of people think. (In the short-run, in truth, they actually cost money: they don’t involve closing a lot of capacity, so it must still be paid for; they typically involve new investment to make existing capacity better, so that requires additional resources; and – ultimately – patients do still need to be treated regardless of where they are treated, and that care still needs to be paid for.)

So without financial reasons for change, only clinical arguments for change are left. What is it that makes these clinical arguments so difficult to stick? I think there are four reasons.

First, the clinical arguments are complicated, counter-intuitive, and – sometimes – they seem to be unfair. Take an imaginary city where there are four full-blown A&Es (ie they can accept emergencies of any kind), which are all equally good. Now imagine that some technological change happens, which means that only three, full-blown A&Es are sustainable in the long-term (say, a new treatment for stroke requires staff to see a certain number of patients every year to maintain their skills, which requires four units to become three units).

It is hard to make the argument for this change. It is complicated: it relies on people recognising that better care sometimes entails what appears to be less convenient (even though convenience is typically the last thing on one’s mind in an emergency). It is counter-intuitive: it relies on people accepting that there is no level of investment which could make all four services safe. And it seems unfair: if all four A&Es are originally equally good but one needs to go, how can you choose which one to switch off?

This is where I have more sympathy with the ‘Sir Bruce Keogh position’ over the ‘Nick de Bois position’ (I apologise to both for oversimplifying their arguments). Given the complexity of clinical arguments, it is vital that politicians should not seek to gain a party political advantage that would be detrimental to the long-term interests of patients – the argument can only succeed with a minimum of ‘noise’ to the contrary.

But the next three reasons make me sympathise more with Nick de Bois.

The second reason clinical arguments hardly ever stick is because they are rarely clear-cut. Take our city of four A&Es. All it would take is for a single doctor at the under-threat A&E to go public with their criticism that the change will ‘cost lives’ and the clinical case for change is shot to pieces (and, indeed, such behaviour by doctors often happens with the tacit support of the hospital where they work). And if the clinical case for change does not seem to be strong enough, the hospital concerned might even take the proposal to close their A&E to judicial review – not a concept unknown to the NHS. The NHS needs to hold a mirror up to itself here, because when its leadership talks of politicians ‘opposing reconfigurations’, those politicians are not in a ‘politician vs NHS’ battle (a battle which they would surely lose); all they are actually doing is taking sides in a ‘NHS vs NHS’ battle. If the NHS spoke with a united voice in favour of a reconfiguration, there would be no opposition for a politician to join (a point, to be fair to him, which Sir Bruce was trying to make in his Guardian interview).

The third reason why clinical arguments don’t stick is because the NHS designs them to be hard to win. Take our city of four A&Es. What local people really like about having an A&E is the reassurance that if they have a sick child, or a nasty cut or a broken ankle then they can get somewhere close by, quickly. But I think people also recognise that they would not always go to their nearest A&E for very serious injuries or illnesses (they must recognise this, otherwise the London stroke reconfiguration would not have proceeded without a much greater fight). So surely in our example the NHS has an option to keep all four A&Es open for local people, and all four A&E signs up, with stroke emergency services alone centralised on three sites? Walk-in patients would notice no difference; and emergency stroke patients wouldn’t care.

There is a parallel here with the real-world, where – in North West London – the NHS is arguing that, of its eight A&Es, three need to be switched off. But surely there is an option where all eight could be maintained as ‘A&Es’ in some form, but with some services centralised on five sites? Someone living right next to Ealing Hospital, for example, already accepts that they would be blue-lighted to Charing Cross if they had a stroke. Why wouldn’t they be able to accept similar arguments for other services?  And if the NHS in North West London doesn’t accept this, then their reconfiguration proposals are likely to be long drawn-out, messy and possibly unsuccessful.

To be fair to the NHS in North West London, however, such an approach would require some national clarity about what the public expect of an A&E. When I was in government, we sought to develop such a piece of work on the ‘nomenclature’ of A&E. It proved harder to develop than we thought, but I still believe it would help the NHS immeasurably if that work saw progress. Indeed, I hope it is now part of Sir Bruce Keogh’s review of the future of urgent and emergency care.

The final reason why clinical arguments hardly ever stick is that 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? It is a can of worms. For a start, it undermines the clinical case for change; but worse, it actively invites local politicians to get involved. Their job, after all, is to fight for public spending for their constituencies: if they are told that something bad is happening to their constituents because there isn’t enough public money then they see it as their job to fight for that money. If the NHS really wants to undertake a reconfiguration on clinical grounds, then it should just say it – not corrupt its message with arguments about finances, which instantly charge the reconfiguration proposals with the political arguments they are trying to avoid.

So I agree with Sir Bruce that politicians (and professionals) should never oppose reconfigurations on the grounds of narrow self-interest. But I must also agree with Nick de Bois’s message to the NHS: that if the NHS wants reconfigurations to be successful, then they need to be clearly-communicated, as acceptable as possible to local people, and argued for solely on the clinical grounds which should predominate.

That, of course, applies to the majority of reconfigurations that take place for clinical reasons. I have avoided those reconfigurations which take place for financial reasons – but I shall return to this subject tomorrow.