Commissioning: further issues - Health Committee Contents

Written evidence from Dr Sally Ruane (CFI 44)

I am a member of the Health Policy Research Unit, De Montfort University, Leicester. I have undertaken some research and consultancy work on the question of service reconfiguration, some of this with my colleague, Prof David Byrne, Durham University. Our work has focused largely on the concentration of some hospital services into fewer, larger units, with particular attention to the "clinical case for change".


There is an expectation that the anticipated GP Commissioning Consortia will be able to drive service reconfiguration through their command of much of the commissioning budget. This may be the case; however, consortia are likely to encounter a number of difficulties in so doing. Service reconfiguration is complex; service redesign in one location can have unintended consequences in another. Some services, particularly hospital services often depend upon a complex of interdependencies so that the withdrawal or physical reorganisation of some provision can affect the quality and viability of other provision. Service design, thus, often requires a regional or even national overview and requires mid to long-term planning. There is a danger that consortia will adopt a short-term approach, particularly, in a context of financial constraint and that service reconfiguration will be shaped by this consideration rather than by long-term planning. Some consortia my not possess the necessary planning skills. The Health Overview and Scrutiny Committees which had at least the potential for some "bite" are to be disbanded. Oversight by health and wellbeing boards offers the theoretical possibility of checking inappropriate service redesign but it is not yet clear how effectively these boards will function. By the time they have developed a way of functioning effectively, many reconfigurations may already be underway. There is a strong possibility that Local HealthWatch will be relatively weak and ineffective at least in its early stages.


The experiences of the Labour government demonstrated that the process of reconfiguration is not an easy one, especially in relation to the securing of public consent. Frequently, reorganisation involved the closure of a local service to which some members of the public objected, triggering local campaigns. Sometimes, proposals to move care "closer to home" included moving some care to more distant or hard to reach locations or selling-off local institutions, again triggering public discontent. In particular, public trust in local NHS decision-makers was often strained. Distrust arose in some instances from a belief that NHS justifications for reconfiguration on the grounds of service improvement were merely a cover for service cuts which were in reality finance-driven; in other instances, it arose from a suspicion that a decision had already been made and would be implemented regardless of the outcome of the formal public consultation exercise, rendering the consultation meaningless. This could be exacerbated by the lead NHS body declining to organise public meetings where the plans could be publicly discussed or declining to attend meetings where these had been organised by members of the public.

Public disquiet or outright opposition to reconfiguration plans slowed down the process of reconfiguration during Labour's term in office. It is possible that during the lifetime of this Parliament the public will be more prepared to accept the closure of hospital services or their relocation elsewhere since they will occur in a context of widespread public sector cuts and not in a context of unprecedentedly high NHS funding which was the case during much of Labour's term in office and where service closure was more difficult to comprehend. On the other hand, public opposition may recur as anger at the general package of public sector cuts develops. This could be compounded where the public perceive conflicts of interest: for instance, if the commercial rather than clinical interests of commissioners are thought to be shaping the design of services. There may also be continued opposition where the public finds that the case for improved services is unconvincing.


Where services are being concentrated, reconfigurations may be justified on the grounds that, although a service which used to be provided in a local hospital is now to be provided in a more distant city and access has been worsened, the quality of care given will be better. Alternatively, where services are being transferred out of hospital into the "community", reconfigurations may be justified on the grounds that care is being brought "closer to home" whilst remaining at least as good as it was. Both of these policies can destabilise DGHs, threatening (in the minds of the public) to reduce them to "locality hospital" status.

One danger in the way in which commissioning might drive service reconfiguration is where commissioners adopt proxy measures for quality. In the US, for instance, the decision some years ago by the Leapfrog Group (130 of the Fortune 500 companies insuring between them 35 million people) to establish a minimum volume requirement for coronary artery bypass grafting attracted a good deal of criticism from more critical researchers.[88] This reflected a belief that health care outcomes are superior in large units or where doctors see higher volumes of patients and these arguments have been deployed in English reconfiguration cases also. However, the evidence for the claim that higher volumes of cases will lead to better patient outcomes is problematic. Two key systematic reviews[89] [90], analysing research up until 1996 and 2000 respectively, found some evidence of a link between volumes of cases and quality of outcome in a small number of procedures such as paediatric heart surgery and some forms of cancer surgery but emphasised the methodological shortcomings of much of the research which weakened the policy significance of the findings. Since 2000, further studies have been undertaken. There are, however, a number of persistent problems with this body of literature: the vast majority of the evidence relates to surgical procedures rather than medical interventions; surgeons and hospitals with the same volumes of cases can have very different outcomes; although there is some good evidence regarding neonatal care and paediatric heart surgery, the vast majority of the research is on adults; and there are significant methodological shortcomings in the research with more sophisticated studies less likely to find evidence of a volumes/outcomes association.[91], [92] Overall, there is no general relationship between volumes and quality; there is evidence of an association in some procedures and conditions but the magnitude of the relationship varies considerably and where a volumes/outcomes relationship is demonstrated to exist, this tends to be true only on the average. As a result, causation may not be clear and the significance for policy cannot easily be inferred.

The argument that some services should be centralised has been used in some reconfigurations involving proposals to close A&E departments. These often engender public opposition for reasons which are understandable. A&E is a universal and upon demand service. It contributes to countering the inequities of access that characterise some other parts of the service since it is considered accessible and useful by typically marginalised and excluded groups. Patients generally know where their A&E services are; they know they are available at any time; they know that they (or their children) will be treated whatever the nature of the ailment. The College of Emergency Medicine[93] estimates that around 95% of attendees can be treated well in their local A&E with just 5% of cases needing the more specialised emergency care provided only in certain hospitals.

Another justification for concentrations which needs to be handled with care is staffing considerations. There are several different staffing arguments which may be raised in any reconfiguration. They include: recruitment problems, retention problems, maintaining skills, the requirement to meet standards laid down by the Colleges or other guidance, the implications of meeting EWTD requirements and the implications of MMC. These ought to be analysed separately in reconfiguration decision-making but are not always. There have been significant rationalisations of maternity units, for instance, in Greater Manchester. Although documentation has referred to "optimum" sized units, we do not have a body of evidence pointing to a relationship between the numbers of births in a unit and the quality of outcomes for mothers and babies. Decisions about how many units and of what size have been justified on the basis of clinical judgement rather than research. Closures of some maternity units in favour of fewer, larger units seems to be driven by different kinds of staffing constraints: accommodating the minimum safety standards required by the relevant professional and other bodies, providing a certain throughput of mothers for junior doctors in training and ultimately shaped by resource constraints (available numbers of staff and financial constraints). In other words, the 'optimum' size of a unit may be more determined by input than by outcome considerations. There is a fine balance here because although what can be provided is always shaped by available resources, designing services around training needs could be considered to be putting the cart before the horse.

It is not obvious that the concentration of services into fewer units will raise large savings[94] since economies of scale are exhausted at a relatively small size and there are difficulties in managing well very large hospitals and diseconomies arise.

February 2011

88   D Shahian and S Normand (2003) The volume-outcome relationship: from Luft to Leapfrog, Annals of Thoracic Surgery 75: 1048-1058. Back

89   Fergusson B, Posnett, J and Sheldon T (1997) Concentration and Choice in the Provision of Hospital Services, Report 8 of the NHS Centre for Reviews and Dissemination, University of York. Back

90   Halm E, Lee C, and Chassin M (2002) "Is volume related to outcome in health care? A systematic review and methodological critique of the literature", Annals of Internal Medicine, 137: 511-520. Back

91   Halm E, Lee C, and Chassin M (2002) "Is volume related to outcome in health care? A systematic review and methodological critique of the literature", Annals of Internal Medicine, 137: 511-520. Back

92   A Gandjour, A Bannenberg and K Lauterbach (2003) Threshold volumes associated with higher survival in health care. A systematic review, Medical Care, 41: 1129-1141. Back

93   See Academy of Royal Medical College (2007) Acute Health Care Services: Report of a Working Party, London: AMRC. Back

94   Posnett, J (2002) "Hospitals in a Changing Europe." In European Observatory on Health Care Systems, ed. M McKee and J Healy. Buckingham U.K., and Philadelphia: Open University Press. Back

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Prepared 5 April 2011