There was no “clever form of words” to spare the SoS’s blushes in the end.

When the Department of Health issued Mr Lansley’s agreement that Chase Farm should have its A&E replaced with an urgent care centre on Monday his statement said “the safety and sustainability of local NHS services are at significant risk unless decisions are taken.”

He stood outside Chase Farm for a photo before the election and presumably will stand outside North Middlesex Hospital for a photo when their new facilities are opened next month.

It’s fair to say the time in-between has been quite frustrating for management.

When David Cameron first promised Labour a “bare-knuckle fight” over closing DGHs in 2007 Chase Farm was on the list of those under threat.

Of the 27 listed four years ago it’s interesting to observe how many are still there.

Local MPs condemned the north London decision as simply “wrong” but the question is how far this unlocks proper reconfiguration for the rest of the country and London in particular.

Once it’s merged Chase Farm with North Middlesex, Barnet Hospital will be up for grabs, would The Royal Free be interested? Would UCLH?

Former Barnet and Chase Farm chief executive Averil Dongworth is now at Barking, Havering and Redbridge University Hospitals, a report on which is also sat on Mr Lansley’s desk.

If BHR’s King George Hospital is the next to centralise services in this way maybe the rest of the capital’s commissioners can push through their closures too.

Ealing and wherever has to go in the Imperial-West Middlesex link-up could join Chase Farm and the services-closed-temporarily-on-safety-grounds-but-now-forever Queen Mary’s on the finished list.

What of the other big driver of reconfiguration, the Tripartite Formal Agreement process being pushed out of Richmond House?

The DH is adamant they will all be signed off by the end of September, as of the 13th there are 15 out of 72 on their TFA webpage.

A lot of these are the low-hanging fruit and both the large/problem hospitals and the surely-too-small-to-live trusts are yet to make an appearance on the list.

Most regions have at least one of each:

Yorkshire and Humber has small-ish Scarborough & North East Yorkshire and £900m+ Leeds Teaching, the South West has £90m Weston Area Health Trust and North Bristol, five times its size.

The east of England and east Midlands also fit this pattern.

Smaller trusts Bedford, Milton Keynes and Northampton have been looking at an acute service review with similarly-sized Kettering plus Luton & Dunstable.

But if the latter pair were to detach themselves from the ASR they’d presumably look to larger neighbours to the north and south respectively.

In the West Midlands George Eliot Hospital (£108m) is fighting for continued independence while Sandwell & West Birmingham awaits the result of the McKinsey study into PFI-dependent non FTs.

The North West has started putting tiny Trafford into large Central Manchester but is having trouble with £557m Pennine Acute Hospitals.

Pennine and franchise management candidate St Helen’s and Knowsley are among the trusts whose march to FT is now the subject of a National Audit Office study. There are others in the Midlands and elsewhere, HSJ understands.

London has rolled big, troubled and small into a single McKinsey-led bit of work, the West Middlesex-Imperial review is considering how best to organise services across £149m West Middlesex and its AHSC neighbour Imperial, six times the size.

The TFAs themselves are considerably less interesting documents than they used to be.

Ever since Imperial’s original document lifted the lid on their financial problems and the Royal National Orthopaedic Hospital floated the possibility of a private franchise in one they’ve been a bit less open.

For example, Royal United Hospital Bath’s plan to merge with neighbouring specialist FT the Royal National Hospital for Rheumatic Diseases is well known.

The RNHRD’s three-year strategy document said it is both boards’ “stated strategic intent” to merge but there is no mention of this in Bath’s TFA.

Bath are open about needing the SHA to pay off the £13.7m it still owes the DH from 2007/08.

Bail-outs to make it to FT seem to be ok with Matthew Kershaw and Ian Dalton, Southampton are getting a bespoke credit facility and Lewisham are presumably due something similar.

So, we all know which mergers, acquisitions and “acute service reviews” are in the open but I’m told there’s as many again “in the undergrowth” - also that the appetite of the big teaching hospitals for out-of-town acquisition has returned.

Where would make sense? Answers on a Powerpoint slide.

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