Reconfiguring NHS services: necessary but fraught with difficulties

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With the NHS facing growing pressures on all fronts, following the general election the next government is likely to begin a new round of NHS service reconfiguration planning. In addition, work will continue to implement the new care models – such as urgent and emergency care networks and modernised maternity services – set out in the NHS five year forward view. So what are the challenges around service reconfiguration? And what evidence is available to help guide this planning process?

At the beginning of April, the National Institute for Health Research published the final version of the report, Insights from the clinical assurance of reconfiguration in the NHS, written by The King’s Fund. When writing the report, we had access to more than 100 reports written by experienced clinicians (the National Clinical Advisory Team) who offered independent expert advice on proposed service reconfigurations. We sought to learn about reconfigurations: what drove them, what lessons could be learned, what evidence was used in planning the changes, and what ultimately happened. Those considering any type of health service reconfiguration should read the report, along with our companion publication on the evidence base for reconfiguration.

We found that those considering reconfiguration often have a limited evidence base to draw on and that few reconfigurations achieved the financial savings they promised. However, a thin and ambiguous evidence base should not be a reason to maintain the status quo if real improvements could be achieved with a new service model. It simply means that innovators need to be realistic about the expected benefits, honest about what they can’t predict, and committed to learning and evaluation so that we might one day have a better evidence base for the system to draw upon.

The most challenging part of NHS service change is gaining the support and co-operation of local people and political leaders. It will be of little surprise to those who work in the NHS to hear that organised campaigns against service changes have meant that many planned reconfigurations were ultimately delayed, changed or stopped altogether.

Engaging patients and the public in service design is important, but doing it well can be challenging. Equally, the National Clinical Advisory Team frequently reported poor clinical engagement, particularly where new service models would change the ways clinical teams worked across multiple hospital sites or in the community. Without clinicians united behind service reconfiguration – leading, designing and being spokespeople for change – it is even more difficult to achieve the support of politicians and the public. 

Providers and commissioners need to resist the temptation to open a formal public consultation with options contrived to lead to a predetermined conclusion. Enlisting local people and their political representatives as partners much earlier in the redesign process would help to increase support and reduce the likelihood of opposition. Ongoing community interaction, with NHS managers and clinical leaders building connections with local patient groups, business and third sector groups, and political leaders could provide a better way forward.

Some may worry that this approach does not address other harsh realities affecting service reconfiguration – spiralling financial deficits in the acute sector; unrelenting increases in demand; politicians unwilling to countenance service changes affecting established institutions. But in fact, we need to take a co-operative approach to major reconfiguration if we want to achieve success and tackle these problems. One notable feature of the reconfigurations we looked at was that none of the changes were driven by patients demanding better services or change, but by financial or workforce challenges.

At first, I thought of a reconfiguration as an optimisation problem that an economist armed with a decent clinical evidence base could solve every few years: X services run by Y staff on Z sites. But as we argue in our new report, reconfiguration of health care is something much more complex, and is an inherently uncertain and a continuous process. In an ideal world, clinicians, managers, patients, local people and politicians would always be challenging the status quo, and asking ‘can we do better?’.


Kate Varnfield

Social work,
Social care
Comment date
15 April 2015
I think that people are fed up with the constant meddling with the NHS without any benefits to be had by the people using the service. Changes occur without proper consultation, without long term planning and knee jerk reactions to political imperatives.
Change is a process that is built on good practice, but change is being driven for the sake of privatisation, and good practice has not been allowed to embed as change happens too quickly and cannot be properly audited.
If we think about the monumental disastrous business decisions made under the guise of ever more efficiency in the NHS, such as PFI and the computerization of all medical records then the NHS would not be in such dire straights,
The NHS should be above any transitory political party with populist sound bites. It is too highly prized and valued, and is the bedrock for a civilized and democratic society.
No reconfiguration should proceed unless it is for the long term. All political parties should sign up and commit to the principle that the NHS was founded upon.

Stephen Smith

retired Research Fellow,
Comment date
17 April 2015
There has never been a public mandate for the plan and no desire for a branding of the service and PFI use. I also believe that any deep rooted change should be agreed beforehand across parties and by the public. These present changes have emerged partly by inspiration and partly out of necessity but unfortunately the majority of the general public is still unaware of it.

K Ashton

Local Authority
Comment date
18 April 2015
Whilst Matthews theoretical viewpoint provides a useful insight and I agree that changing what people do and how they do it is often a rate limiting factor even when people support proposed changes, I would say that the one critical element that has been omitted from this piece is the impact of a workforce development system that largely perpetuates history. A further "wicked problem" and stumbling block to an efficient and effective approach is our disconnected individual record held within multiple and separate organisational boundaries.

Judith Wright

Manager/Neuro Counsellor,
Comment date
18 April 2015
I believe, like many others, that the restrictive practices in the NHS are damaging - people who are British and undoubtedly have the expertise in their field who cannot get an HSPC for instance.

Michael Vidal

Comment date
19 April 2015
As touched upon in Matthew's article reconfigurations and certainly none that I have been engaged in have not been done primarily to improve services. It is for this reason that they meet with opposition from patients and the public. I have never seen a reconfiguration which would improve a clinical pathway because that has not been the purpose. Arguably Healthcare for London was the exception however even in that case it was looking primarily at the primary care pathway and not at the whole patient journey.

Until you have a reconfiguration that looks at the whole pathway from primary care through secondary care to community care then reconfigurations will fail. The Transformation of Primary Care in London Programme has the potential to do this.

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