I work as a consultant on service redesign and, with colleagues, have been asked to examine many proposed reconfigurations on behalf of local authorities which are scrutinising the plans of their local NHS. Although there will always be local peculiarities and local differences, we have come to recognise the common elements in the NHS plans put forward. These are:
- The desire to avoid implementing the European Working Time Directive (or EWTD) which would involve employing more doctors
- Reducing the number of A&E departments
- Expanding community services and primary care as cheaper substitutes for acute services.
Typically, the rationale presented does not make a persuasive case; nor, in most instances, does it attempt to comply with the stipulations for a genuine business case as set out in the Capital Investment Manual or the Treasury Green Book. When the Independent Reconfiguration Panel (IRP) , which gives expert advice to the Secretary of State on contentious proposals, was established in 2003, it found that business cases were non-existent or lacked crucial relevant information. Moreover, most proposals referred to the Panel were substantially amended during the process of review, over a period of many years in most instances. Standards, however, have improved markedly since then, as the NHS has responded to criticism and the resources committed to developing large scale reconfiguration proposals have increased as well, and would have reached £12m in the case of proposals in South West London had reconfiguration gone ahead. Despite these significant additional resources expended on trying to bring about an effective reconfiguration, NHS organisations have continued to find it very difficult to present the compelling business case that the proponents of reconfiguration suggest exists. What are the issues that lie behind this failure?
1. It is not clear what the NHS is trying to achieve by reconfiguration
If reconfiguration is to ensure that there is better weekend cover, it would be cheaper to employ a few more consultants, to press for better rotas and to implement the European Working Time Directive than to close departments in up to half the hospitals across England. As the Prime Minister said during the recent country-wide floods, we are a rich country. There seems little justification for not implementing the EWTD since it first came into effect in 1993 especially given the period of unprecedented growth in NHS resources seen between 2000 and 2009. The former chairman of the IRP also came to the conclusion that the EWTD was not the obstacle that it was presented as being. If reconfiguration is designed to achieve better value for money, meaning as good or better services at lower cost, this too seems unconvincing. In the case of plans to reconfigure services in SW London (a project entitled ‘Better Services, Better Value’ ), the proposed reconfiguration offered no immediate improvements in meeting quality standards, and after full reconfiguration, just £6.3m of additional benefits could be identified – out of a budget of over £2.7bn. To arrive at these paltry benefits, £200-£300m of capital would have had to be invested, tens of millions of pounds of capital charges would have had to be paid, redundancies would have had to be funded and an unproven model of service configuration would have put at risk the services of 1.7 million people. It is tempting to conclude that the business cases are written as business cases to achieve the preconceived goal of reconfiguration not improvements in quality or efficiency.
2. Future sustainability problems are exaggerated and there are cheaper, safer options to improve quality and efficiency that are not getting the attention they deserve
Despite all the claims to the contrary the NHS is not out of financial control. The propaganda image is of a future dystopia swamped by the very elderly in a society unable to look after them. Because of this we must rush to close Accident and Emergency services! These are not reasoned arguments to justify change but attempts to bounce decision makers into taking premature decisions before evidence is available. In fact the projections of the chronically ill show increases but these are not overly alarming; the number of people with one, two or three long term conditions is expected to hold steady at around 15 million, although the number of people with three long term conditions is expected to increase to 2 million. There is, though, more positive news in the three most costly areas of health care with improvements in outcomes for cancer, mental illness and diseases of the circulatory system. Another problem frequently mentioned by proponents of hospital reconfiguration is the ‘epidemic’ of obesity, but closing A&E departments does not look like a rational response to the health problems that can be expected to flow from it. More rational responses would be “fat” taxes and other public health initiatives taxing the source of pollution. Projections of a £30 billion shortfall in funding over the next five to ten years assume the continuation of a real terms freeze in funding. This is a political choice and not a requirement of sound fiscal policy. Even if governments in the mid-term do decide to downgrade the NHS as a political priority and hold funding down in this way, other policy options can be considered. The NHS has handed back £5.5billions to the Treasury since 2010 and was heading for a surplus of hundreds of millions of pounds in 2013/14. These funds should be returned to the NHS on top of planned expenditure. The NHS employs fewer clinical staff than comparable countries in Europe and overall the UK spends 2% of GDP less on healthcare than in comparable countries in Europe such as France, Germany and the Netherlands. A combination of recruiting extra staff plus implementing a carefully designed pay policy would provide a better compromise than the adventure of wholesale reconfiguration. A more targeted approach to tackling obesity and air pollution could be taken by imposing costs on industry rather than the NHS. However, the NHS and government appear to have been beguiled by large consultancies encouraging “big solutions”.
3. Expanding community services will not substitute for acute service
Investment in community services is often presented as reducing the need for acute interventions. However, most of the authoritative evidence suggests that this claim is unproven. While some community-based interventions may improve health quality and outcomes it is not clear whether these could substitute for acute care. For example a major meta-analysis of initiatives to reduce unplanned admissions undertaken by Bristol University concluded: “There was evidence that education/self-management, exercise/rehabilitation and telemedicine in selected patient populations, and specialist heart failure interventions can help reduce unplanned admissions. However, the evidence to date suggests that majority of the remaining interventions included in these reviews do not help reduce unplanned admissions in a wide range of patients”. While there is no shortage of anecdotal “evidence” and small-scale case studies, those who take a more measured approach in the UK or elsewhere either at best reserve their judgement or are forced to admit there is precious little supporting evidence for the case for wholesale reconfiguration. In fact, when it comes to the concentration of specialised hospital services, the UK has a remarkably centralised system already. For example Nigel Edwards commented on obstetric departments as follows: “The UK is a particular outlier in terms of the size of obstetric units – some of the numbers of births suggested as a minimum by some of the UK participants at our European Summit were larger than the biggest units in other countries.” What reconfiguration proposals offer is the replacement of hospital-based care, especially care in accident and emergency departments, with expanded community services and primary care services. It is also likely that any shift towards community health services will involve outsourcing to the private sector; and the evidence from social care shows that when this is done in conditions of financial stringency the result is a severe loss of coverage and quality in the services finally provided. No one is saying resist all change, but our advice is to be very cautious about the claims that are being made to support proposals for reconfiguration as the solution for the problems facing the NHS.