News / News analysis: Closing encounters

Who would be an NHS manager, particularly in the run-up to this general election? Charged with finding up to £20bn in efficiency savings and improving quality over the next four years, many hospital boards have produced plans that will mean closing wards. Naturally, such moves will attract local opposition, but as general election fever mounts they are also being pounced upon by national politicians.

Conservative parliamentary candidates and the party’s national leadership have been at pains to show that they would oppose cuts. The Conservative draft health manifesto, published earlier this year, says it would stop the ‘forced closure of A&E wards’. Should his party win power, shadow health secretary Andrew Lansley would also halt the closure of maternity units while evidence is gathered about their clinical viability. Earlier on there was talk of a wider moratorium on hospital closures.

Ministers have also attacked managers over planned closures. Last month, health minister Mike O’Brien rounded on the leaders of Gloucestershire Hospitals NHS Foundation Trust, who were planning up to 200 phased-in bed cuts, starting with 95 this month. He said that in the current climate, the NHS needed ‘imaginative managers who will focus on the quality of care’. ‘I make no bones about it – I will name and shame managers who are making slash-and-burn cuts across the health service,’ he added.

Mr O’Brien labelled the trust’s insistence that its plans related to the current economic situation as ‘nonsense’ and a ‘product of a lack of imagination by managers’.

So where does this leave the Gloucestershire trust? It is involved in further talks with stakeholders, including local people, following criticism over the level of engagement prior to announcing its plans. The proposals to have a phased closure of between 150 and 200 beds were part of its programme to save £27m to £30m in 2010/11.

The trust was not expecting to make any redundancies when its plans were announced. The bed closures were to be set alongside improved discharge arrangements and better use of theatre and outpatient sessions.

It was also hoping to reduce the number of patients who failed to attend outpatient appointments – the trust said more than 39,000 appointments are missed but not cancelled each year, costing it more than £4m in lost income.

Responding to its critics, the foundation pointed out that a greater proportion of hospital patients were being safely treated as day cases than in the past. In addition, a greater range of rehabilitation services were now provided in community hospitals and other community settings.

A spokesperson said: ‘Gloucestershire has one of the highest lengths of acute hospital stay in the country and we acknowledge that reducing this over time and in a planned way can lead to better quality care for individual patients and their families closer to where they live and better use of resources.’

Jon Restell, chief executive of NHS managers’ union Managers in Partnership, said the Gloucestershire situation could be repeated across the NHS. ‘I don’t think the case has been won for the switch of resources out of hospitals and into community and home care,’ he said.

He acknowledged that ministers would say that local NHS managers, including commissioners, could manage their proposals better, taking staff and the public with them through better consultation. But he added: ‘The outcome is still about getting beds closed. So if you still have opposition, then politicians have to move in and support the plans.’

Mr Restell said it felt as though managers were being set up to fail. Elective care policy was dictating a move away from the traditional model, which involved a stay in hospital, to ever-shorter stays, day cases and outpatient procedures. Bed cuts were a natural consequence of this, but hospital managers were not receiving the backing of those setting the policy. Added to this, PCTs are being asked to engage with stakeholders to inform planning just as their management capacity is to be cut by a third.

‘The strategic direction is around efficiency. The length of stays in England has been cut dramatically, though there seems to be even more efficiency to be gained,’ said Mr Restell. ‘But although efficiency is being demanded, the consequences, such as closing beds or increasing throughput, are being decried by some politicians.

‘What hasn’t really bitten yet is that if you are successful in placing more patients into the community, fewer staff will be needed in hospital. The two things will come together and as soon as that happens people will start to attack managers.’

Support for closures

Not every interest group is against bed closures. In its pre-election briefing Share the power, National Voices – an umbrella organisation for more than 200 health and social care charities such as the Alzheimer’s Society, Macmillan Cancer Support and the Stroke Association – was realistic about the current climate.

It said changes that are largely cost-driven would happen, whichever party wins power. The changes may involve proposals for closing and merging hospitals, closing parts of hospitals, or changing the locations from which services are provided. Sometimes this will be the right outcome, it added.

‘The reflex “save our local hospital” is the line of least resistance and not always the right one,’ the briefing said. ‘Not all local hospital care is good enough, safe enough, or in the right place. Many patients want to have more care and treatment nearer to home. Too many people are admitted who shouldn’t be, and stay longer than they should or want to. Some care is better carried out in the community, or in specialist centres further away from home.’

However, the briefing also said that money saved must be reinvested in improving local NHS care and that replacement services should be operational before the old one is closed.

Centre-right think tank Reform called for a reduction in the number of hospital beds, particularly in the areas with the highest density of beds – London, the North East and the North West of England. In a report, Fewer hospitals, more competition, Reform said the NHS had rightly reduced hospital beds from 270,000 to 160,000 over the past 20 years but these had mainly been seen in specialist care.

Local managers were constrained by the Department of Health’s centralisation of decision-making, it said.

‘A further constraint on the ability of PCTs to effectively reconfigure services is the reluctance of ministers and MPs to support local hospital reconfigurations.’

The report added: ‘The Conservative Party is wrong to pledge a moratorium on service redesign should it win the election. Such a moratorium will hold back the improvement in efficiency the service needs.'

While the spotlight on hospital cutbacks and the stalling of many trusts’ plans could disappear once the election is over, local opposition is unlikely to melt away overnight. Whatever the outcome of the election, managers will be getting ready to explain their plans and bracing themselves for criticism.