Not the right way to go about it

James Gubb, 8 November 2007

Let’s get one thing straight. Hospital reconfiguration is necessary. There are too many district general hospitals (DGHs) in England. All the evidence suggests that acute care, such as A&E, cardiology, neurosurgery, liver transplantation, some cancer surgery and major vascular surgery, is more safely provided in larger hospitals where doctors have the right skills, experience and equipment to treat the sickest patients.*
But that does not mean the Department of Health should go about it by just unilaterally cutting payments – or, more specifically, not offering ‘top-up’ premiums – for specialist procedures to some DGHs they’ve decided should no longer be carrying them out, as has been revealed today by the HSJ.

Judged against those hospitals that will get the premiums, those that don’t get them will have had it (at least in terms of the specialist services they offer). The DH will no doubt insist that the hospitals it’s withholding the top-ups from are those that commissioning groups, made up of a number of PCTs, have already recommended to lose specialist services. But, for one, the DH has revised upwards the number of hospitals to suffer cuts with apparently little consultation. And more importantly, trying to push the whole thing through the back door via complex tariff adjustments that even policy analysts struggle to grapple with is just plain cynical. At the very least we could at least be open about it. There’s already enough public resentment.
A better way would be to use the transition process to Foundation Trust status, strong PCT commissioning and market mechanisms already provided by payment-by-results. If hospitals are treating less and less patients, some will inevitably have to cut their specialist services, because they simply won’t be profitable. There are many trusts that in their current form are inefficient, with too many specialities and too few patients. They shouldn’t be propped up; instead they should have to look at the possibility of partial mergers, acquisitions and the closure of specific services or, indeed, the creation of specialist centres. Market mechanisms should be allowed to determine change, not direction from the top.
*For example, the Royal College of Surgeons recommends that hospitals providing emergency surgery should serve a minimum catchment population of 300,000 people. Research carried out by ippr shows that on this criterion eight out of ten SHAs currently have too many hospitals that carry this out.