Search the website

Hospital reconfiguration: Good practice guide

4 May 2007

1. Introduction and background
Late last year, the Department of Health indicated a wave of hospital service reconfigurations, including suggestions that up to 60 District General Hospitals may be ‘reconfigured’.

Reconfigurations can take a range of forms including departmental reorganisations, mergers and closures of departments and hospitals and the provision of new service units. Essentially, however, reconfiguration means that the way in which services are delivered will change, such that some services will be provided in more specialist centres and others will be provided closer to the patient’s home. Acute care, for example, such as accident and emergency and specialist surgery, may be concentrated in fewer locations, whilst more routine services, such as diagnostics and rehabilitation, may be provided locally in community hospitals and clinics.

The Government’s move towards hospital reconfigurations should be considered alongside other initiatives, such as the introduction of care closer to home as detailed in the White Paper ‘Our health, our care, our say: a new direction for community services’, which sets out the Government’s intention to move more services out of hospitals into treatment centres, and community facilities. Similarly, the increase in referral management, new commissioning arrangements, payment by results and ensuring patient choice all affect the way in which services are delivered, and will therefore affect the way in which hospital services are configured.

This guidance has been produced by the BMA’s Central Consultants and Specialists Committee (CCSC) to highlight the key principles it believes should be fulfilled in order for service changes to be acceptable to the profession, and to assist consultants in their involvement in any such plans.

2. Key principles
Financial strain within the NHS has created suspicion that service reconfiguration is being driven by short-term financial pressures, rather than on the grounds of clinical need. Although the financial crisis in the NHS cannot be denied, and needs to be addressed, the CCSC believe that reconfiguration driven by financial pressures alone is unacceptable and could risk patient care.

The CCSC believes that to ensure that reconfiguration is not purely driven by finance, clinicians must be involved from the outset to build the case based on clinical evidence and to allow them to engage with the public about the clinical desirability behind the changes proposed. There has been a notable lack of clinical engagement in the process of reconfiguration to date and this has caused problems.

Where there is good evidence of patient benefit, or where safety and standards can be preserved and enhanced, reconfiguration in some areas maybe desirable. Critically, we believe that reconfiguration of hospital services must stand up to scrutiny in terms of clinical gains.

The CCSC has developed principles which it believes should be fulfilled in order for service changes to be acceptable to the profession. Reconfiguration is acceptable where it is:

• Evidence-based
• Clinically-led in partnership with patients
• Safe
• Maintains or enhances standards of care across a health economy

These criteria are essential in securing the support of consultants for reconfiguration plans in their locality. Decisions about hospital reconfigurations can only be taken locally and require full clinical and patient engagement.

3. Case for change
The CCSC recognises that in many cases the reconfiguration of hospital services can be justified on clinical grounds. An underutilised A&E centre that is not greatly benefiting its local population, for example, may be drawing resources away from one that desperately needs more capacity. Provided a good patient transport infrastructure is in place, it may be justifiable to re-grade or even in rare circumstances close the unit.

Similarly, clinical problems may stem from geographical dispersion of hospital sites and these problems may provide legitimate reason for considering the viability of a hospital site or services. For example, research suggests that if heart attack services were centralised so that all hearth attack patients could receive angioplasty, approximately 550 fewer patients would die per year . Concentration of services, in some cases, may make the best use of expensive equipment and allow for round-the-clock services. In remote areas, however, smaller hospitals may be needed to provide a minimum level of access. It is important that appropriate transport arrangements are considered in all reconfiguration discussion.

In other situations, change might mean shifting care into the community, allowing patients to gain access to more services closer to their home, rather than travelling to hospitals. Patients could stay in hospital for shorter periods after surgery and could be treated for long-term conditions, with appropriate support in community hospitals or at home.

4. Review of proposals for service change
In October 2006, David Nicholson (Chief Executive of the NHS in England) asked Sir Ian Carruthers (former acting NHS Chief Executive) to review all existing proposals for major service change. The review (28 February 2007) contains 17 recommendations which are broadly in line with the CCSC’s views and the CCSC welcomes Sir Ian’s recognition that early clinical involvement and thorough consultation are essential to the process. We look forward to seeing the recommendations implemented in full.

Sir Ian states that:
‘Without exception the proposals are not about closure or simple downgrading. They are about the NHS adapting itself to new patterns of care, using leading edge technology and care pathways to treat people more quickly, more safely and in more convenient settings.’

‘In order to deliver better outcomes for patients, some specialised services like trauma, should be centralised in specialist hospitals, in order that clinicians and frontline staff have access to the best equipment and experience, and patients receive the specialist care they need from specialist staff.’

A number of recommendations in the Review focus on improving processes and ensuring early clinical engagement. Such recommendations include:

• A full business case setting out the clinical and patient benefits of service change… should be produced for all proposals, and should be reviewed by the SHA before clinical consultation begins.
• A senior clinical lead should be identified at the outset, and should have support to help them ensure that clinicians are involved in the proposals for change.
• Before embarking on the process, it is important to have a clear evidence based communications and stakeholders engagement strategy, which is managed and effectively delivered throughout.

The Office for Government Commerce, which provides an independent oversight of government project management, will also be involved in oversight of hospital reconfiguration. In light of the size and importance of change in the NHS it is perhaps peculiar that the NHS has not had such independent scrutiny in the past.

The key issue for consultants now is to ensure that Sir Ian’s recommendations on clinical engagement are fully implemented and implemented in a way that does not merely provide a clinical fig leaf for non-clinical reconfiguration. The CCSC will be seeking to ensure that clinical engagement in line with recommendations is developed and implemented.

5. Hospital reconfiguration in Scotland
The policy position in Scotland on reconfiguration of services was originally set out in Delivering for Health Delivering for Health, Scottish Executive, November 2005 (November 2005). The intention was to make the NHS as local as possible by extending the availability of locally-responsive community based services and providing more local diagnosis, treatment, advice and outreach. In taking decisions about service changes, the Scottish Executive indicated that it would approve proposals where:

• There is evidence of improved clinical outcomes
• There are resource or workforce constraints and it can be demonstrated that:
  - the services are highly specialised and a clinical benefit will result ,or
  - the services included 24-hour receiving of seriously ill patients, or
  - the services involved care for medically unstable patients through the night, and
  - service redesign will not achieve a sustainable outcome.

On this basis, local decisions to close A&E services currently provided at Monklands Hospital in Lanarkshire and the Ayr Hospital, Ayr were approved by the then Health Minister. However, the new SNP government took the decision on 6 June to reverse these closures and instruct the health boards responsible to look again at their original plans and produce revised proposals that will enable A&E services to continue at all three sites in Lanarkshire and at both sites in Ayrshire.

These revised proposals will be subject to a process of robust independent scrutiny that will also apply to all future significant service change proposals in that an independent panel will assess the safety, sustainability, evidence-base, patient benefit and value for money of service change proposals; and be satisfied that due account has been taken of local views. In taking final decisions, the Cabinet Secretary will operate a policy presumption against centralisation.

BMA Scotland’s position is that it supports the principle that care should be as local as possible but as specialised as necessary and that the key factor in any decision is a well staffed service that is high in quality and safe for patients. NHS plans based on political expediency in response to local pressures will not improve patient care. Local views therefore have to be balanced with clinical considerations, sustainability, safety and value for money. BMA Scotland also supports public consultation at an early stage in any proposed major reconfiguration, before any decision on the preferred option has been taken.

6. Getting involved – questions you need to ask
Clinical involvement is essential and you should seek to be involved in reconfiguration consultations wherever possible and to discuss such matters with your general practitioner colleagues. If your department or hospital is likely to be affected by reconfiguration you should consider whether any of the following justifications for reconfiguration are being cited:

• Increasing specialisation and complexity of skills ( eg: angioplasty, vascular surgery)
• Fairer distribution of services
• Provision of treatment closer to the patient’s home and the benefit to patients who have long-term conditions
• Enhanced delivery of a service (for example, by combining two small adjacent maternity units)

Where it is claimed that a reconfiguration is based on a clinical problem, consultants should already be aware of the problem and, perhaps, have been involved in bringing it to light.

If the four points above are not demonstrably present, or if local consultants appear not to have been involved in the plans, you might like to consider raising the questions below with your hospital’s senior management team either as an individual or as a group.

BMA Divisions can assist you in addressing your concerns. For contact details of your local BMA Division, please contact askBMA@bma.org.uk. A number of BMA Divisions are already taking an active role in cases where the motives for reconfiguration have been questioned.

You can also raise your concern in our discussion forum (http://www.bma.org.uk/ccscforum3.nsf/alltopics?OpenView&Login) which will help keep CCSC informed of developments across the country. The CCSC is keen to receive feedback from consultants and case examples of where reconfiguration has been carried out either successfully, or unsuccessfully. If you have specific concerns, but would like them to remain confidential, these can be emailed to info.ccsc@bma.org.uk.

You might also consider writing to your local Member of Parliament, Member of the Scottish Parliament, Welsh Assembly Member or Assembly Member in Northern Ireland.

7. Key Questions
To what degree is the reconfiguration based on financial pressure?

• Are services being cut without detailing the investment in the services that will replace the scaled-down service or demonstrating a genuine reduction in the need for a service? Are services being lost in totality entirely to save costs (eg facilities for mental handicap)?
• The reconfiguration must not only offer a solution to short-term deficits; it must be part of a programme of service improvement sustained by financial stability.
• Where there are moves to improve timely discharge of patients, which is both clinically appropriate and financially desirable, will there be adequate follow-up healthcare and social support closer to patients’ homes?
• Are there any financial dependencies that will change as a consequence of a reconfiguration and weaken other NHS services, potentially destabilising them? Pathology services perhaps.

To what extent will it be clinically led and evidence-based?

• Have you been properly consulted on the reconfiguration? Clinicians, especially consultants, should be engaged early on in the process.
• Can you be confident of the clinical reasons for the reconfiguration? For instance, were the choices for reconfiguration driven by political considerations, perhaps to retain a popular but clinically less preferable site?
• How will the clinical benefits of the reconfiguration be measured (against national standards of care, for example)?
• Have the potential effects of any transfer of services been assessed and mitigated in advance?
• Have the responsibilities for clinical delivery and competency been defined in advance of any transfer of services? Is there clinical involvement and leadership in the proposal?
• Where an Emergency Department is moved away from a hospital, does adequate emergency support remain for the rest of the hospital?

To what extent will there be public consultation?

• How will the public (patients and carers) be engaged in developing the proposals for change? How will their views be followed-up? The public need to understand the case for change, how it will impact on them and what the benefits will be.
• Have public communications been considered, to ensure relevant and clear information is easily accessible to the public? Information needs to be provided in a way that is easily understood.

How will the reconfiguration affect other aspects of the service?

• Where services are reconfigured there may be knock-on effects for other areas of the health service. Does reconfiguration destabilise other departments to their detriment?
• For instance, will a hospital remain clinically viable where a specialty is moved to another site?

Have education and training needs been taken into account?

• Will the reconfiguration result in a reduction in training opportunities for trainees?
• Will the reconfiguration result in a drop in the number of trainees’ posts?
• How will research and teaching be delivered if reconfiguration takes place? This will need serious consideration, especially in areas near to a medical school.
• Have providers of medical education been consulted?

8. Where reconfiguration directly affects you (Individual and collective rights)
Depending on the nature of the reconfiguration you may be asked to change your job plan (including a potential drop in Programmed Activities), be asked to relocate, or, in extreme circumstances, you may be subject to a redundancy process. There have already been examples of consultants being given redundancy notices in 2006 and where the BMA’s representation has averted a redundancy.

Therefore, regardless of the broader arguments surrounding reconfiguration, you should consider how reconfiguration might affect you personally and how you need to respond to protect your own personal interests.

If you suspect that your personal employment situation will be affected you should contact AskBMA (0870 6060828 / askBMA@bma.org.uk) immediately to access the BMA’s industrial relations’ services. AskBMA advisers will initially discuss your situation and escalate your representation as your individual circumstances demand.

9. Links

CCSC's statement on hospital reconfiguration

Sir Ian Carruthers' Review of service change and reconfiguration proposals

BMA's Health Policy and Research Unit’s debate on the challenges of improving clinical engagement