Don't be deceived by the rhetoric of reconfiguration

Michael MacDonnell, in his HSJ article earlier this year, introduces a welcome new note of strategic scepticism by pointing to the lack of evidence to justify shifting services into the community, “integration” as a catch-all solution for healthcare delivery, the use of preventative medicine, and responding to an increasing, ageing population by reducing access to acute care or by centralising services.

‘If there are problems these are mainly of the NHS’s own making and do not justify claims of an urgent threat requiring reconfiguration’

However, the NHS England head of strategy still harbours within, or perhaps projects out, a latent radical threat when he says: “The case for radical change in the NHS grows daily.”

As someone at the sharp end of reviewing radical NHS reconfiguration proposals on behalf of local authorities, it seems the rhetoric of reconfiguration gets in the way of a more reasoned approach.

Therefore we find that reconfiguration is always driven by an urgent threat.

The “urgent threat” has a long history as a rhetorical device used to promote controversial proposals. For example the 1832 Reform Act was viewed as a way of averting deeper social upheavals along French lines, or the institution of the welfare state to meet the threat of communism in the post-war period. So MacDonnell claims “future trends threaten to overwhelm the health service” and Sir David Nicholson refers to the £20bn challenge.

But all political parties agree, as does the public, that real term spending on the NHS should be maintained. Any financial pressures can be managed strategically through pay policy given 65 per cent of expenditure relates to pay. Put simply, if there are problems these are mainly of the NHS’s own making and do not justify claims of an urgent threat requiring reconfiguration. The risk is that the £20bn savings programme will imperil the whole enterprise.

It is often said by those pursuing reconfiguration that we have “history on our side”.

Having “history on your side” has been a handy rhetorical device for both conservatives waxing lyrical on the supposed benefits of ancient constitutional liberties and land rights but also Marxists, who claimed insight into the development of productive forces and how best to marshal them.

‘The evidence that more out of hospital community care reduces rather than merely complements acute care is sparse’

In the case of the proponents of NHS reconfiguration, the ancient lore of promoting preventative medicine is fostered on the one hand, while the white heat of technology promoting increased centralisation and specialisation is cited on the other.

Unfortunately the evidence that more out of hospital community care reduces rather than merely complements acute care is sparse. Preventative medicine has singularly failed to stem the tide of rising demand ever since Bevan used it as an argument to get the Treasury off his back in the 1950s. Nor is it clear that technology promotes centralisation rather than decentralisation as costs of technology tumble and specialists can become more mobile.

It is often claimed that reconfiguration is only opposed by reactionary vested interests, frightened of change.

On this pretext the “reign of terror” in the French revolution was launched and the gulags in the Soviet Union were filled with dissidents.

It enables the easy dismissal by NHS “radicals” of the “reactionary” arguments that the supposed benefits of reconfiguration might not be obtained; that the results of reconfiguration could be worse than the current position; that the upheaval and costs of change are damaging to the sustainability and security of current services; and, that smaller scale, less risky and less costly options may be better ones. To speak up for reason risks being classed as “not one of us”.

Reconfiguration is necessary because “no change is not an option”.

This is an argument speaking from the experience of previous failures. It is akin to the gambler doubling the stakes. Examples abound in development economics of desperate South American or African regimes seeking to fast track history.

In the NHS it has manifested in grandiose IT projects; as well as sweeping reconfiguration proposals promoting integration of competing organisations and measuring success as turning people away from attending A&E services at levels not previously achieved in NHS history.

‘We are all less likely to be deceived if we are aware of the rhetorical tricks being used to influence due process and proper analysis’

Don’t misunderstand me. It may be that once the business case has been completed we will all be persuaded there is a compelling clinical and economic case for change, based on sound evidence and backed up with persuasive plans that show benefits exceed costs; that the adverse consequences for access, capacity and resilience of the system will be outweighed by the better quality on offer; and finally, that there were no better, cheaper options available that could have achieved the same end without incurring the risk that centralisation of hospitals will leave behind loser hospitals, destined for running down and future closure as staff and patients vote with their feet.

This is a possibility but we are all less likely to be deceived if we are aware of the rhetorical tricks being used to influence due process and proper analysis.

Roger Steer is executive director at Healthcare Audit Consultants. The company is currently representing Sutton and Merton in evaluating reconfiguration proposals in south west London.