In September, Andrew Lansley accepted the Independent Reconfiguration Panel’s recommendations to proceed with changes to services at Chase Farm hospital in North London. These changes continue to be very unpopular locally, but as the Secretary of State’s statement acknowledged, these were hard choices about the safety and sustainability of services. And then he added: “This is not about money. We are not making cuts to local services.”

Whether or not local campaigners agree, this statement is typical of the Government’s persistent unwillingness to admit that the financial pressure on the NHS will eventually force changes to local services.  It runs counter to the message from Canadian policy makers and politicians who managed a similar process of reform through a serious economic downturn: be honest with the public about the impact of cuts to health services. 

Honesty with the public over the scope of the NHS efficiency challenge is a critical first step to building the case for change locally

This was one of the reflections from a seminar held earlier this year by the Nuffield Trust to explore the impact of the 1990s recession on health services in two of Canada’s provinces, Saskatchewan and Ontario. Provincial Governments, which are responsible for providing Canada’s publicly funded health service, were forced to reduce large deficits by rapidly cutting public spending for several consecutive years. Health services were not spared.

When it became clear that wage freezes and staff lay-offs wouldn’t balance the books fast enough the Governments of Saskatchewan and Ontario squared up to a more daunting challenge: the conversion and closure of public hospitals. Between 1992 and 2000, Ontario (13 million people) reduced the number of hospitals from 225 to 150.  Smaller, more rural Saskatchewan (population of one million) “converted” 52 rural hospitals between 1992 and 1993, avoiding outright closure, but reducing services and staff.

The two provinces took very different approaches. Ontario’s government delegated authority to a time-limited independent restructuring commission, which engaged with local stakeholders including the public and the media and issued binding recommendations to hospitals to close or merge. Decisions could be challenged and re-worked, but could not be rejected outright.

Elected politicians in Saskatchewan engaged in a more centrally led process, spending many months travelling to meet opponents of change face to face in town hall meetings across a huge area, much of it sparsely populated. Reorganised local health boards implemented changes, which were piloted first, and the boards were given central support with data analysis, communications and deadlines for implementation.

In Canada as a whole, there was no apparent increase in mortality or deterioration in clinical quality during this period but waiting times increased and there was a sustained decline in public satisfaction with health services.

The different paths taken by the two provinces helped build legitimacy for the changes. Common to both were strong leadership, clear messages about the need for change, intensive engagement with local stakeholders including clinicians, a strong evidence base and an overall purpose for reform that included but went beyond the need to save money.  Above all, politicians had to accept responsibility for deeply unpopular decisions.

And that’s the most unpalatable lesson for the ministers in relation to the NHS: good processes can make change more legitimate but it will always be unpopular.

This article has also been published on the The Guardian Healthcare Network website. Further information on the Canadian experience of health service reform (video interviews, charts and a report of the event) are available from the dedicated event page: Managing a health system through an economic downturn: a masterclass.

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