Jeremy Taylor: NHS needs a fresh prescription for change

But until now, it has not felt real. The main political parties have fallen over themselves to reassure the public that they will protect health spending if in government. There has been little talk of cuts.

Now there are signs that the phoney war is coming to an end. "Hospital wards to shut in secret NHS cuts," screamed one headline this week. "Cuts in the NHS are already happening," warned senior doctors in a letter to the Guardian. All over the country, nervous health service managers are gearing up for major service changes, including hospital closures.

How worried should we be? It depends where the cuts fall – and how the decisions are made. The largest slice of NHS funding goes into hospitals, yet hospital bed numbers have been declining for years as patterns of healthcare have evolved. New drugs allow people with long-term conditions to be looked after better at home; advances in surgery have massively reduced the need for long stays in hospital.

The NHS could go further in this direction. It still admits too many people as emergencies – for example, diabetics and asthmatics – because their care has not been managed properly in the community. It keeps elderly people in hospital too long for lack of adequate personal care at home.

Most people die in hospital even though most people say they would rather die at home. Casualty departments are full of people who could have been treated by out-of-hours GPs, or minor injuries units. And we know that in certain circumstances – for example, the treatment of major head injuries – it is safer to be treated in a specialist centre, even though these may be further from home.

The bald fact is that not all hospital care is good enough, safe enough or in the right place. The research evidence shows that it is better to provide more care in GP surgeries, in the community and at home; to support and educate people to look after themselves, and to make less use of hospitals. This is better for health, better for patient satisfaction and better value for money.

But there is a problem. In this country, we do not like closing hospitals. MPs and local councillors can get elected on a "save our local hospital" ticket. The enquiries into the preventable deaths at the Mid Staffordshire NHS Trust revealed deep public dissatisfaction with that hospital, but try closing it and people would no doubt take to the streets.

Why? A big part of it is that the NHS has been very poor at managing what are called major service redesigns. The case for change is not properly made; the promised new services feel nebulous compared with the loss of bricks and mortar; there is a token "consultation" on what is really a decision already taken behind closed doors. The public is justifiably suspicious.

The Independent Reconfiguration Panel, the body which adjudicates on disputed NHS service overhauls, lists "inadequate community and stakeholder engagement in the early stage of planning change" at the top of its list of reasons for referral, with "health agencies not giving enough thought to local opinion on money, transport and emergency care and inadequate attention given to responses during and after consultation".

National Voices, a coalition of health charities that speaks for

patients and carers, is demanding a different approach. We want people to be treated as grown-ups. Managers must do their homework and present schemes that will improve quality and safety, not just cut costs. People must be informed and involved from the outset. They must have a say in the new services that replace the old. They need proper

reassurance on matters of concern, such as transport. Local leadership is required. If there is a medical case for change, doctors should be out there making it. And local politicians need to be responsible. "Save our local hospital" is the line of least resistance and not always the right one.

Finally, national politicians need to set a good example. Local managers, doctors and politicians will be reluctant to stick their necks out while the political parties are competing to promise the public that all is well with the NHS. Let's have an honest debate. "We have some difficult choices to make and we would like you the public to help us make them," is what they should say. It's a novel approach, but one that is timely. After all, it's our NHS.

Jeremy Taylor is chief executive of National Voices, a coalition of more than 200 national health and social care organisations.