At the end of July the NHS Chief Executive wrote round with the new Service Reconfiguration rules. His letter formalises the four straightforward tests that the new Secretary of State wants applied to every proposed service reconfiguration:

support from GP commissioners;

strengthened public and patient engagement;

clarity on the clinical evidence base; and

consistency with current and prospective patient choice.

Unfortunately the straightforwardness ends there, and the letter immediately runs into the heaped sands of inherited bureaucracy. The four tests involve commissioners, the public, patients, and (tacitly) the providers concerned, so it is unsurprising that these feature prominently in the letter. You would expect there to be some other process, given the risk and money involved in reconfigurations, but is it really necessary for local commissioners to involve all of the following? In order of appearance in the letter the cast list is:

• Strategic Health Authorities (SHAs)
• Local Authorities (LAs)
• Local Involvement Networks (LINks)
• Office of Government Commerce (OGC) Gateway
• National Clinical Advisory Team (NCAT)
• Independent Reconfiguration Panel (IRP)
• LA Health Overview and Scrutiny Committees (HOSCs)
• Cooperation and Competition Panel (CCP)

The involvement of so many bodies invites a number of criticisms. It is centralising and weakens local decision-making. It delegates complex judgements to bodies who may be expert in their subject but unfamiliar with the local particulars. It causes delay. It confuses the process, and thereby pushes blame back up the system to the Secretary of State. It is expensive.

So expect further reform, as the Coalition Government sets to work simplifying and localising decision-making in the NHS.

Something else is odd, though, and this goes to the heart of the Secretary of State’s new approach. The covering letter says:

The Secretary of State has also made it very clear that GP commissioners will lead local change in the future.

If the Secretary of State wants a market in healthcare, then surely this is going in the wrong direction? In a normal market, customers don’t design products; companies do. So healthcare providers should conduct the market research and consult the stakeholders, and if that goes well then they can design and take the business risk on developing new service configurations.

To be fair, the Secretary of State only walked into his office a few weeks ago, and cannot be expected to reform everything all at once. But, as the evolving policy on service reconfiguration shows, he will have his work cut out to achieve more straightforward and local decision-making in the NHS.