The question of how to make change happen to a National Health Service that is beloved to the last bedpan has been preoccupying health secretaries for at least 50 years. As each one has to find out for themselves, change in healthcare is extraordinarily complex, not least because no one quite knows what it ought to look like. Now it is Jeremy Hunt’s turn.
The regime that will prevail if the care bill goes through the Commons unchanged is one more botched effort to deal with the unintended consequences of a crisis that originates in failure. Clause 119, which deals with hospital closures, means that good hospitals that are functioning well could have their best services asset-stripped in order to prop up a neighbouring trust facing bankruptcy. It could end up shaping the way healthcare is provided without paying proper attention to the wider needs of the community that it is supposed to serve. It is a failure regime that will almost certainly make failure more likely.
Clause 119 is a rapid rethink after a court ruled that the trust special administrator – in effect, the receiver – of the South London healthcare NHS trust couldn’t force neighbouring Lewisham hospital to run down some services to make the South London trust more financially viable. What is happening in South London now will be coming soon to a dozen or more of the scores of hospital trusts across England that – after the fierce budget squeeze – are teetering on the edge of collapse. Reconfiguration of the health service is undoubtedly needed. But it must not happen like this, driven by too many of the wrong considerations – narrow questions of short-term finance – and not enough of the right ones – the most efficient way of delivering the best, most affordable care, from district nurses to specialised cancer units, to everyone in the area.
Veterans of attempts at health reform are usually convinced that in the end there has to be some kind of top-down command and control system. Otherwise local interests obstruct every change. All politicians remember Kidderminster 2001 – when Dr Richard Taylor snatched a safe Labour seat with a campaign in defence of his hospital’s A&E unit – and shudder. No secretary of state would sacrifice the power to intervene for political reasons in order to pursue the greater good, at least not if they valued their job. If this seems unduly cynical, look back only a few weeks to the case of Mid Staffordshire NHS trust, where the trust special administrator and the health regulator, Monitor, had painstakingly agreed a programme of managed decline, which involved among other measures losing maternity services to the larger University Hospital of North Staffordshire. Hours before the recommendations were to be announced, David Cameron told the Commons he thought mid-Staffs needed its maternity unit. The report was sent back for reconsideration. Jeremy Hunt had to rewrite his statement to MPs.
Mr Hunt could reasonably warn that there is now real concern that delays in reconfiguration are leaving some services in some hospitals in protracted death throes. That means – local campaigners should remember – that some will be less safe than they could be. But that does not justify forcing through change on the back of a rushed and narrowly focused process. What is so alarming is that in the process of driving through changes so big they can be seen from space, the mechanism for making primary care the driver of reconfiguration got swallowed up in second thoughts – and now there’s no mechanism to provide an evidence-driven holistic assessment of service need that ordinary people can believe in.
Sweeping up all the powers of reconfiguration into the office of secretary of state and his appointees will make that worse. That’s likely to be the first big headache for the highly rated if controversial Simon Stevens who takes over NHS England next month. Early in his career, he commissioned NHS services for Brighton. Useful expertise for the man who has to piece together the parts that have fallen off the NHS aeroplane and get it airworthy again.