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Will a hospital ever close again?

With changes to the health bill diluting GPs' power to shape local hospital services, Alisdair Stirling weighs up the potential impact

Political hot potatoes don't get much hotter than hospital closures.

In 2006, Tony Blair famously tried to argue that hospital closures would save lives – but didn't actually go on to close any.

Pressure to rationalise hospital provision in England is now at bursting point. Financial forecasts are dire and NHS chief executive Sir David Nicholson wants to see £20bn worth of savings urgently made. Everyone agrees this requires moving more care out into the community – reducing demand on hospitals, making the case for keeping them all open even weaker.

Last month, Dr Peter Carter, head of the Royal College of Nursing, said England had far too many acute hospitals in urban areas – and that these were a drain on the system and should be replaced with care in smaller, community-based units.

That followed a warning in January last year that hospital closures were now inevitable over the course of the next five years.

Labour peer Lord Carter of Coles suggested ‘massive reconfiguration' of the NHS was necessary as it adapted to reductions in funding and changes to healthcare practices. Speaking at a conference to mark the opening of a new private hospital, he said: ‘Closing a hospital is probably one of the toughest things in politics. And yet in the coming five years we are going to have a massive reconfiguration and rationalisation if we are going to get through this [financial crisis].'


All change

The changes to the health bill last month could fundamentally alter the dynamics surrounding such controversial decisions.

Notably, the amendments hand responsibility for the NHS and any service cutbacks or hospital closures back to health secretary Andrew Lansley.

The Conservative 2010 manifesto pledge was: ‘We will stop the forced closure of A&E and maternity wards, so that people have better access to local services.'

Roy Lilley, former NHS trust manager and health service consultant, bemoans the fact the amendments have given politicians a foothold in the decision-making again.

‘One of the things I liked about Lansley's original vision was that it pushed these decisions out of reach of politicians. Now we're going back to 1922 and the Tomlinson report on London hospitals. Nothing was ever done because nobody had the political will.'

The bill amendments also pave the way for local councillors to occupy a majority of places on a health and wellbeing board.

Opposition to hospital closures is fiercest at this local political level. Tory backbencher Nick de Bois, who warned against too much watering down of the original health bill, is also locally fighting controversial plans in his Enfield constituency to close its 24-hour A&E department.

Consultants – albeit ones who do not work for a local provider – will also sit on governing bodies and consultants who do work for local trusts will sit on clinical senates.

NHS Alliance chair Dr Mike Dixon has voiced his concerns that clinical commissioning groups (CCGs) will be over-constrained or straight-jacketed by these changes: ‘We need to ensure that CCGs are able to deliver for patients. To do that they need to have a strong enough mandate, free of centralism and interference.'

Dr James Kingsland, NAPC president and clinical commissioning network lead for the DH, says the closure issue cannot be avoided.

‘If we don't change estates, then we will never meet the QIPP challenge. There are four facets to it – workforce (but some say too many people are losing their jobs), moving money round the system by changing the tariff, closing buildings or redesigning services.

‘The biggest cash release will be change of estates. Up to a half [of the £20bn]could be achieved through service redesigns, but we need to do all [of the four].'

But Dr Kingsland doesn't see clinical senates making hospital closures or downsizing any more difficult.

‘Clinical senates shouldn't be advising on the day-to-day commissioning but on the strategic issues such as health inequalities.'


Contract or close?

Dr Amit Bhargava, chair of the Crawley clinical commissioning group and national co-lead of the NHS Alliance clinical commissioning federation, predicts rationalisation rather than actual closures.

‘I think we'll be able to reduce contracts with hospitals overall by something like 40%. That will certainly lead to some rationalising. A lot of services like dermatology that are only in hospitals for historical reasons will come into the community,' he says. ‘But I agree with Sir David. I don't think we'll see hospitals closing. It will be politically very difficult to shut them down.

‘The changes made to the health bill will make dicussions much more robust. But consultants and politicians will still have to make rational decisions. And all those people need to understand that they will be sitting round a commissioning table – not a provider table.'

Dr Oliver Bernath, founder of Integrated Health Partners, agrees rationalisation is highly likely, but that the impact on hospital numbers will be limited. He says: ‘There are three different things involved in a hospital closure: specialist services, staff and employees, and the physical infrastructure.

‘It would be ridiculous to slim down the capacity of experts within the NHS. We need the consultants and nurses. There simply aren't going to be large lay-offs of staff and employees. There might be a shift of more nurses into the community but it is likely to be an organic transition.'

He adds: ‘On physical infrastructure – what to do with the big buildings – there could be some downsizing, but I don't expect to see many signs up saying: "This place is now closed." I don't think the wrecking ball is going to swing that much.'