Fate of local hospitals a key concern in marginal seats
There are few issues more likely to provoke community outrage than a threat to a local hospital.
In the struggle to protect standards and remain solvent, small district general hospitals are often seen as vulnerable.
Can they survive as care becomes ever-more specialised, safety ever-more stringent, and finances ever-more tight?
With an election approaching the question has never been more urgent.
Last year thousands of people took to the streets of Stafford to protest against plans to downgrade services at the local general hospital.
It was an impressive show of loyalty to preserve a place seen by many as a cornerstone of the community, despite its notoriety for past failings.
Part of the problem here, as with many other district general hospitals, was the size of the trust.
Advances in treatment mean some conditions - including major trauma, heart attacks and strokes - are handled increasingly by teams of specialists in large regional centres. That means smaller hospitals often struggle to keep staff, maintain standards and balance the books.
Andy Black, who has run several NHS hospitals and is now with the health consultancy Durrow says this has produced a damaging stalemate.
"If you pursue the centralisation of acute care you end up with a significant proportion of the smaller rural and semi rural hospitals which are deemed non-viable. But the citizens and the voters don't see it that way. So the political pathway to closing that hospital is closed, and the NHS pathway to making it successful is closed."
But earlier this summer the chief executive of NHS England, Simon Stevens, warned against too much centralisation. He stressed the opportunities offered by new technologies to develop local services.
Airedale hospital, perched on the edge of the Yorkshire dales between Keighley and Skipton, offers a promising model. It serves a mainly rural area with a lot of elderly people.
The trust has set up a telemedicine service allowing patients and carers to speak to nurses and doctors remotely, at any time of day or night, seven days a week, via a visual display on a tablet.
The idea was initially set up for people in prison, and has taken off. It serves thousand of people in care homes across the country, and is also being used to support people at the end of life in their own homes.
The trust's chief executive, Bridget Fletcher, says using telemedicine in this way has helped secure the future of this hospital, and could work for others.
"We are trying to get the expertise to the person, rather than the other way round. And if you think about it that could completely change the system of healthcare that we've got at the moment, from one that's primarily based on buildings - with people in buildings - to one based on the technology and diversifying the expertise into different areas."
The health think tank the Nuffield Trust is setting up what it calls a "learning network" of smaller hospitals to share ideas like this. They also include working as part of a network so doctors can keep up their skills moving from one centre to another, or developing much closer links with GPs. The Nuffield Trust's chief executive Nigel Edwards says this is a vital challenge for the NHS.
"One of the things of most interest at the moment is how do you provide high-quality local acute medicine so when you have perhaps an older person who's become dehydrated or confused you don't have to ship them fifty miles away in an uncomfortable ambulance only to find they have to come back again the same day.
"How do we safely see patients who might have a surgical complication but in most cases don't, and can continue to treated locally? How do you manage the risk of that and what type of workforce do you need?"
Andy Black from Durrow has produced a blueprint to secure what he calls a "gold standard" service from small local hospitals. He argues rather than trying to keep patients away from A & E, people should be encouraged to regard their hospital as their local health system - bringing in GPs to work alongside doctors on the wards so people can register at their hospital.
He also suggests scrapping out-of-hours services such as walk in centres, and amalgamating paramedics and senior A & E nurses into a single team. He says these hospitals can thrive if they get the right support.
"One hopes that the commissioners would then see their responsibility to make these hospitals successful and to commission care in a way that supports these hospitals, not undermines them."
Andy Black says there are up to 30 seats across England with small general hospitals whose futures hang in the balance. Many are marginal. Little wonder then, his ideas are causing a buzz among MPs and in Downing Street.