The decisions of the Lanarkshire and Ayrshire and Arran health boards to close accident and emergency services at Monklands and Ayr hospitals have long looked like classic examples of choices made with more regard for the benefits to management than with improvements for patients.
That made them bitter battlegrounds for those charged with delivering health services and the patients who use them. In simple terms, the argument that it was worth bypassing your nearest hospital in an emergency for one some distance away in order to get the best possible treatment failed to convince anxious patients. The independent scrutiny panel's backing for the instinct of the patients is a victory for their argument that an emergency service that is not easily accessible is a step backwards. Although the timing of the Scottish Parliament election ensured these particular closures also became a political battleground and the Health Secretary, Nicola Sturgeon, imposed a swift stay of execution for the A&E services when she took up office, an important degree of neutrality was brought to the process by requiring both boards to submit new options to an independent scrutiny panel.
The panel's final reports on both boards' plans find significant flaws in the case they made for closure, but in analysing their submissions, they also raise far-reaching questions about the assumptions behind the increasing centralisation of hospital services. It is not only the Lanarkshire and Ayrshire and Arran health board chiefs who should now take note of the panel's finding that the argument that specialist consultants, concentrating on particular procedures, produce better outcomes for patients has been applied too generally and sometimes using out-of-date evidence.
Further findings that not enough consideration was given to the potential of building on the current services and that the assessment system used was weighted in favour of managers at the expense of doctors will, together, tend to reinforce the suspicion that a neat administrative and financial solution may have been favoured over the more complex requirements of improving the service over separate sites.
As in urban regeneration, the idea of removing what already exists and starting again from scratch is attractive to service designers, but is rarely the best solution for those whose lives are affected by the end result.
The sustained campaigns against the moves to centralise A&E units in Lanarkshire and Ayrshire, and continuing anxiety expressed about the new, alternative proposals for a reduced service, not least in letters to The Herald, is evidence that - irrespective of the merits of the decisions - the consultation process itself was fatally flawed.
Scrutiny panels are a new phenomenon in the process of health service decision-making in Scotland, but they have the ability to subject arguments made by a board to a closer inspection than has been available under the current system of public consultation. Questionnaires and public meetings allow some expression of dissatisfaction with proposed changes, but they do not allow sustained challenge to the arguments. Among the proposals for the future running of the NHS in Scotland is direct elections to health boards. That would provide motivated or knowledgeable members of the public with an opportunity for direct participation, but does not guarantee a wider public scrutiny. These reports are also testament to the level of expertise required by any board member to challenge the arguments of officials.
One criticism is that studies supporting the board's case were accepted while critical ones were overlooked. Part-time board members may not have time to review properly all the evidence independently. On the basis of these reports, there is a case for independent assessment; one finding they do not contain, but which perhaps Ms Sturgeon should consider, is whether scrutiny panels should now be used more widely.
