Reconfiguring hospital services: a bold move to improve health care?

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The need to reconfigure hospital services to improve the quality of care and patient safety is widely understood if not universally supported. Public opposition – often reinforced by local councillors and MPs – to changes in where services are provided often delays these changes, even when the clinical case for doing so is clear cut. How then can the process of reconfiguration be improved to expedite decisions that are becoming ever more urgent?

In a new briefing paper on reconfiguring hospital services, we put forward several suggestions, drawing on our analysis of experience to date. These include the suggestion that the NHS Commissioning Board should set minimum quality standards for key clinical conditions, with these standards being used by the Care Quality Commission (CQC) in registering providers. Hospitals that fail to meet the standards would not be able to provide services for that condition.

Equally important is the need to ensure effective public engagement in consultations on reconfigurations, with the new health and wellbeing boards having a pivotal role in making this happen. Strong clinical leadership is also essential in the areas affected by changes in the location of specialist services. The proposed clinical senates will need to have a clearly defined role, which uses their clinical expertise and broader geographical overview to inform the configuration of services. Monitor must take account of clinical and quality considerations in regulating the health care market and work closely with the CQC to ensure a consistent approach.

Previous work by the Fund analysing experience in south east London concluded that strong strategic commissioning is needed to deliver the service changes necessary to drive up quality of care. Primary care trusts were too small to force through improvements where action was needed across a number of hospital sites. It will be important to be clear where this responsibility lies when strategic health authorities are dissolved and clinical commissioning groups are established. How will they work with the NHS Commissioning Board in handling complex reconfigurations?

Even if these suggestions are taken up, they may not be sufficient to overcome the obstacles and delays in current arrangements. For this reason, we believe two more radical options should be considered. The first would be to make the Independent Reconfiguration Panel the final arbiter of decisions. The second would involve establishing an independent commission – as happened in Ontario – to lead work on reconfigurations at arm's length from government.

The common feature of both options is that they would de-politicise decision-making – equivalent in its own way to the establishment of the Monetary Policy Committee to set interest rates independently of government.


Roger Steer

Healthcare Audit Consultants
Comment date
05 January 2012
I have just seen the responses to my September comment.
In his introduction Chris Ham laments public opposition to reconfiguration and calls for urgent decisions.
My point is that the implications of reconfigurations need careful analysis - including the long term financial implications. Desisions cannot be taken in isolation from the financial consequences. It is telling that there is no financial imperative for reconfiguration despite what many think.
As for the clinical and safety issues these are not always as clear cut as presented with in particular questions over the rush to create obstetrics factories on allegedly safety grounds where the real issue is getting Obstetricians to work more flexibly.
Plus others have pointed out the trade off between quality and access. Local campaigners are right to question the impact on accessibility and inequality of attempts to close local services.
Personally I support moves to reguate consultants workload to improve quality of outcomes before reconfiguration is undertaken urgently as a supposed solution.

Ronald Fernee

Comment date
19 September 2011
Quality and Safety are merely reflections of the budget allowances from the Department of Health. This is all just pettyfogging to justify the Government's winding down of the NHS by cutting off the cash it needs. Otherwise all the hospitals could provide the services of a fully functioning hospital. The potential loss of a proper A&E Department at Chase Farm two was predicted two years ago by the Conservatives that it "Will cost lives." And the same is true about that issue this year and next year. It's just that now they are the party in power and don't like spending the money. This is too important an issue to trust to a body of part-timers like the Independent Reconfiguration Panel, or to a Registered Charity of academics, which is the King's Fund. The time required for MEANINGFUL discussion by the people affected by the changes (reconfigurations) is essential. ONCE A HOSPITAL OR A SERVICE AT A HOSPITAL IS CUT, IT IS NEVER REPLACED.

Dr S. Michael …

Consultant Medical Oncologist,
Comment date
19 September 2011
There are a number of points to make about the briefing paper.

Firstly, the historical context is not really a continuous reduction in hospitals over 50 years as described. The bulk of this followed from the Hospital Plan of 1960 which resulted in the disappearance from the acute sector of the NHS of myriad small hospitals over the next 15 years or so and invented the (acute) district general hospital (AGH). Small hospitals still exist in the private sector, both in the UK and abroad.

The AGH attained economies of scale, Maynard’s group from York published work in the 1990s which suggests they are of optimal scale. It facilitated the evolution of medical practice in secondary care from general medicine and surgery to a predominantly specialist pattern of practice via the intermediate job title of the 1970s and 1980s of “physician with interest;” surgery and gynaecology have followed a similar development.

Three specialties were formally declared centralised and if this is the pattern for reconfiguration it requires very careful scrutiny.

The second point to make about the briefing is that it makes no mention of deprivation or of inequality. Two of the specialties centralised in the 1960s were thoracic surgery and radiotherapy. There is very clear evidence for both of these that when patients lives in a deprived locality their access to these services is reduced by over 30% if the service is more than half an hour’s travel from home. Distance is much less of a problem for the well off. The third centralised specialty was neurosurgery. I know of no published evidence for such a distance-decay phenomenon in this specialty but I would be gobsmacked if was shown not to exist. All these services have failed to develop the capacity required to meet the needs of the contemporary population

The AGH as a whole and its inpatient services in particular are used by people from deprived backgrounds as the healthcare provider of last resort. More deprived people than well off individuals have their cancers diagnosed following emergency admission. To diminish AGH services willy-nilly will be to disadvantage further the already disadvantaged. However AGHs are happy to develop ambulatory care and outpatient services that exploit the multidisciplinary culture they acquired towards the end of the last century; the NHS as an entity that exists for an egalitarian purpose needs this. For cancer patients the ‘acute oncology’ concept that has developed over the last 2-3 years epitomises it, alongside the multidisciplinary teams involved with elective cancer management.

For the sake of the socioeconomically deprived, hospital beds should not be closed until they have been made redundant by these welcome developments and by ongoing improvements in out-of-hospital services to avoid admission and to facilitate discharge. The funding of these developments cannot therefore be predicated on the closure of the beds.

A third point relates to efficiency. An off-the-cuff remark is often heard to the effect that centralising more services will be more efficient. If financial efficiency is implied, the DoH analysis that was unearthed by the HSJ in May gives the lie to this. See

This chimes in with Maynard’s University of York work from 15 years ago. As an immediate practical example, much specialist cancer surgery in Yorkshire is done at the Bexley wing in at St James’s University Hospital. Heart problems in such patients will occur from time to time. The specialist cardiology service they require is centralised at a different hospital. It this an achievement for reconfiguration?

Reconfiguration presents the danger of an NHS that superficially meets the concept of quality that appeals to the middle classes whilst depriving poorer people of the support they ought to be able to rely on.

tim gilling

deputy executive director,
centre for public scrutiny
Comment date
15 September 2011
There are some good points in the paper but it fails to appreciate the role of overview and scrutiny, which has been praised by the IRP - in contrast to what the IRP has had to say about patient and public involvement and consultation by the NHS.

I am pleased that the concept of 'designated services' has been dropped from the Bill because this would have restricted referral powers to a very narrow set of potential service changes.

I remain concerned that council executives may use regulations to be made under the Bill to dilute scrutiny just at the time when executive power is being strengthened (for example through health and wellbeing boards). I think that independent scrutiny should be retained in order to provide a check and balance in the system.

I see health and wellbeing strategies as a key to service reconfiguration. The strategies will have clinical, professional and political buy-in, something that does not often exist in relation to reconfiguration proposals currently.

Chris Ham

Comment date
15 September 2011
To respond to Roger Steer's comment, the Fund's view is that cost savings from reconfigurations are not proven. The argument is about quality and safety as I emphasise in my blog. We put forward the same argument in our brieifng paper.

Dr Paul Worthington

Programme Manager,
Comment date
13 September 2011
Actually, one of the key thrusts of Prof Ham's arguments is that we're not just talking about the short to medium term (and nor should we be !). One of the concerns that I've heard raised about the approach that's been drivne on to the Nicholson Challenge is that it focuses on the year by year short to medium term, rather than looking at the potential for bigger, more strategic change which might relaise bigger financial and clinical efficiencies, but over a longer timescale. I don't think Prof Ham's comments are dissonant from the briefing paper quote; they're two elements of the same issue.

roger steer

Healthcare Audit Consultants Ltd
Comment date
13 September 2011
You would be forgiven for thinking the briefing paper justified the comments from Chris Ham.
Actually it says:"overall there is little evidence to demonstrate that significant cost savings can be achieved from reconfiguration in the short to medium term and significant change frequently requires transitional and capital support".
Methinks there is some division in the camp.
For a fuller review see 13th Sept edition of

S J Burnell

Comment date
09 September 2011
Will hospitals be closed on the basis of Bed-density in any given locality or just on the basis of poor performance?

What if local hospitals get together & collectively reduce their Bed-density in a planned strategy to avoid any individual Closures?

Is it too many hospitals or too many Acute Beds or is it actually all about Productivity of Staff & Beds?

What if a locality has only got good hospitals, but deemed to have too many beds for its Catchement Population?

What if a locality has only got one, poor performing hospital? Will it still be closed?

Pure Competition is a very blunt instrument to determine Acute Hospital Provision - there needs to be a more informed, evidence-based, transparent element of Design.

The Public & the Medics would need to understand the rationale for Closure & accept the evidence.

Will a weak hospital still close if it is shocked into becoming a strong performer (unlikely as that may be) or is the List already written?

What are the metrics that will determine Closure?

Josie Herbert

Solihull Pensioners Convention ( NPC)
Comment date
08 September 2011
Keep our NHS Public -no to any interference from the EU -No to any American Insurance influence -Return to local CHCs
Listen to the Nurses ( my daughter is a Cleft Palette experienced Nurse ) Government interference is detrimental to the Service -leave it to the Proffessionals !

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