As the election campaign ratchets up a gear, and the outcome is anyone's guess, prospective MPs are vying for every last one of our votes. Candidates are keen to tell us how they will make a difference in our local areas; where local service changes are planned, promises to save hospitals or A&E departments are a common theme.
Politicians are also vocal on the topic at a national level – the Lib Dems have lamented unpopular ward closures as symptoms of an NHS too removed from the people it serves. The Conservatives have gone even further – pledging a stop to all forced closures of A&E departments and maternity wards. It's more difficult for Labour to be critical of such changes – the system they have established makes such decisions chiefly the responsibility of PCTs and SHAs in consultation with the public, clinicians and local authorities. But locally, Labour MPs have also campaigned against such changes.
So are local politicians right to campaign against service closures? Predictably, the answer is not straightforward.
The current organisation of services is often based on historical configurations of facilities that local managers may want to change to improve the safety, convenience and efficiency of services. Service closures are usually a result of a service being relocated – either to bring it together with other specialist services to improve outcomes for patients, or to provide it more locally.
A classic line of argument against service closures is to condemn them as cost-cutting measures. But whoever gets the keys to Number 10 on 7 May, in the medium term the NHS is going to be operating with at best very small increases in funding, and at worst spending freezes or cuts. This will be combined with an increasing demand for NHS services as the population ages and chronic diseases become more common. If costs can be reduced, without compromising safety, that's a good thing.
However, the real challenge for local managers is to identify what changes are most likely to achieve these aims, in the context of the specific needs of their population and the particular configuration of services they have inherited.
It is clear that the district general hospital model is no longer ideally suited to a health system that should be shifting its emphasis to managing long-term conditions and providing care in the community. There is also a growing body of work showing that centralising some trauma and cancer services can improve patient outcomes. Other studies have found that it is safe to move some services traditionally provided in hospitals – such as ultrasound, care for some skin conditions and follow-up appointments for non-complex procedures – into GP practices.
But the evidence base for reconfiguring services is limited to a handful of studies covering only a few clinical areas. And what evidence there is also tells us that some apparently common-sense ideas used to support the case for reconfiguration may be flawed. For example, studies on shifting some hospital services into GP practices have found that the services proved to be more costly, as a result of highly paid GPs providing services previously performed by more junior hospital doctors.
Also, closing wards won't always produce significant savings if hospitals still have to bear the capital costs of the space while the service is being provided elsewhere – at an additional cost.
So there are no easy answers, and local managers have to make decisions on a case-by-case basis, with limited evidence; strong loyalties to existing institutions among clinicians, staff and patients; and sometimes inflammatory political debate.
What is required is a well-informed debate at a local level, in which all interested parties participate with an open mind. Managers need to be thoroughly researching and modelling the possible opportunities and risks of any change to services, and communicating these in a clear and accessible way to clinicians, patients and the public. Clinicians and hospital managers need to think beyond the survival of their particular institution to new ways of providing services where there is a good case for these. For their part, patients and the public should recognise that change may sometimes be necessary to improve or even just maintain service standards in the face of the financial crisis, but are right to keep questioning the basis of the plans. A briefing last month from the umbrella organisation for patients and carers groups – National Voices – argued that sometimes service closures and mergers may be the right thing to do. Politicians should take note.