Poll after poll has shown that people from across Britain value the NHS above any other public service or institution. They feel a strong sense of ownership of NHS services and buildings, and – sometimes in the teeth of the evidence – have a high degree of confidence in the service’s ability to meet the needs of themselves and their families at the times when they are most in need. Consequently, time after time, many attempts to change the way in which services are delivered at a local level have foundered in the face of public opposition.
A brief look across recent history serves to underline the importance, if proposals are to succeed, not only of consulting with the public, but doing so in a way that is meaningful to all parties involved. As the Health Select Committee noted in its 2007 report on patient and public involvement in the NHS (House of Commons Health Committee, 2007), “patient involvement and public involvement are distinct and are achieved in different ways. The conflation of these distinct terms and the confusion about the purpose of involvement has led to muddled initiatives and uncertainty about what should be done”. This essay focuses on some lessons from the history of public involvement.
Legal structures for talking to the public are necessary but not sufficient
Although the statutory mechanisms for doing so have changed over the years, legislation requiring the NHS to engage with the public – directly or via representatives – about changes in services has been in place since 1974.
But the existence of these legal duties and mechanisms is not in itself a guarantee that engagement with the public will be effective. The Independent Reconfiguration Panel (IRP) was established in 2003 with a remit to “review proposals for changes to NHS services that are being contested, and… offer support to the NHS and other bodies on achieving successful change.” The IRP has produced three reports on learning from reviews. They all summarise themes common to the reconfigurations referred to the panel, with examples including:
- “inadequate community and stakeholder engagement in the early stages of planning change
- proposals that emphasise what cannot be done and underplay the benefits of change and plans for additional services
- important content missing from reconfiguration plans and limited methods of conveying information
- health agencies caught on the back foot about the three issues most likely to excite local opinion – money, transport and emergency care
- inadequate attention given to the responses during and after the consultation”.
In 2012 the outgoing Chairman of the panel Dr Peter Barrett noted that “one of the hardest subjects for the NHS to broach with the public is the possibility that their existing services may not be as safe or providing the best quality that they could be.” Later in the same paper, he argued that “the challenge to the public is to think more deeply about what the NHS can offer for the money it’s given… What is needed, if we are to progress the agenda on patient choice and public engagement, is open and honest dialogue about these issues.”
If we are to achieve this, we need to be able to connect with the public around the issues which really matter to the public, and to use that connection as a route into discussions on the issues which matter to professionals in the NHS. Drawing on the work of Dr Ellen Stewart for an essay on public attitudes to changes relating to NHS buildings, Cowper (2018) suggests the need to:
- appreciate the underlying relationship between the NHS organisation and the population it serves
- engage early, with genuine dialogue
- accept that service change is politically sensitive
- explore disagreement.
Meeting your own requirements isn't always enough
Among other legacies left to the NHS by Andrew Lansley in his time as Health Secretary, he sought to establish a framework against which proposals for change could be measured by local people and their political representatives. The ‘four tests’ stated that there must be clarity about the clinical evidence base underpinning the proposals; they must have the support of the GP commissioners involved; they must genuinely promote choice for their patients; and the process must have genuinely engaged the public, patients and local authorities.
These tests were announced by the Secretary of State in a speech delivered at Chase Farm Hospital in Enfield shortly after the 2010 general election. But a close examination of this case demonstrates that, as with legal structures, relying on a formalised framework of your own cannot in itself guarantee that satisfactory consultation with the public will take place, and indeed may obscure the need for genuine engagement.
Chase Farm presented an excellent example of a long-standing conflict between the desire of NHS leaders to reconfigure services deemed to be unsustainable, and the desire of local people to maintain local services (Gainsbury, 2011). In 2006 local leaders had developed plans to relocate A&E, maternity and emergency paediatric services from Chase Farm to other hospitals 6–7 miles away. The IRP broadly supported the proposed reconfiguration, but noted that “there was a frequent mismatch between what the Panel heard from the NHS and the apparent knowledge of many of the community groups and members of the public... there is mistrust and the primary care trusts (PCTs) will need to rebuild relationships and restore the confidence of its community.”
With some acerbity the report goes on to say that “the Panel requests the PCTs and the acute trusts to reconsider the benefits of meaningful two-way engagement with both staff and the public as opposed to what was perceived to be a one-way information-giving process.”
Following the 2010 election, the proposals for change were once again referred to the IRP. For the second time, the IRP accepted the clinical and financial arguments behind the proposed changes. The recommendation was finally accepted by the Secretary of State in September 2011, even as he admitted that local people and representatives still felt strongly about the issue.
Changes led at a national level are not immune to the challenges of consultation experienced at a local level. Having sought to change the pattern of delivery of services for paediatric cardiac surgery for some time, NHS England’s ‘Safe and Sustainable’ review in 2011 resulted in a collective decision to establish seven clinical networks across England, each led by a specialist centre. This was a reduction from the previous 11 centres, and passions ran high in the areas which were effectively downgraded. Not only were a number of referrals made to the Secretary of State by local health overview and scrutiny committees, there were several judicial reviews of the process. The outcome of the final judicial review, published in 2013, was to quash the collective decision.
In a comprehensive review of the approach to consultation and engagement the IRP found that “much of the opposition to, and flaws in, the proposals originate in the lack of engagement of a wide range of stakeholders in the co-production of network models of care at the pre-consultation stage.” It has taken a further five years to develop proposals which are broadly supported by both clinicians and patient representatives.
Reflecting on the four tests, in each of these cases professionals – including GP commissioners – were persuaded of the clinical case for change. The nature of the proposals was in effect to limit choice, but with a strong clinical rationale. However, both of these examples highlight the difficulty of persuading the public that what they perceive as a loss – a service being moved to a different physical location – may in fact represent a gain, in a better service more likely to save lives.
If you’re discussing planned changes rather than involving the public in decisions, say so
In 2010, NHS leaders in both London and Manchester were developing proposals to change the way stroke services are organised. The changes in both areas involved selecting hospitals to run specialist stroke services for a larger region. The hospitals within that region were to be viewed as a network with the specialist stroke site at its centre.
Earlier this year the results of a project looking at patient and public involvement in these reconfigurations were published (McKevitt and others, 2018). The research concluded that public engagement had taken place in an effective way even though citizens had not necessarily contributed to the actual system redesign that took place: the value lay in the fact that citizens felt involved in the changes being made and this was intrinsically a good thing for the process.
The two reconfigurations were approached differently, but in each case there was a recognition of concerns expressed by both professionals and the public from the outset, and the need to engage with stakeholders to ensure effective implementation of change. A range of methods were used to involve patients and the public. Often, assumptions made by professionals about the concerns likely to be felt by patients were flawed, but the act of consultation helped to uncover this. In particular, although in both cases the consultations focused on the provision of acute stroke services, patients were most concerned about the arrangements for longer-term rehabilitation.
Overall, the researchers concluded that, notwithstanding the different approaches adopted (and there were valid plaudits and criticism of each), the most significant benefit of each consultation was that once the process was concluded and decisions had been made, patients and the public accepted those decisions, even though in many cases they did result in services moving physically further away. In this case NHS leaders were more successful in positioning change as a gain, rather than a loss.
Poor engagement drives suspicion and disengagement
Not all engagement with patients and the public is about detailed service change. Since 2016 local health and care leaders have been working together to develop Sustainability and Transformation Plans. The timescale for the production of the initial plans was uncomfortably tight, and local leaders were actively discouraged from discussing their plans in public – at least in part due to a concern that taking less than fully developed plans into the public domain may raise public anxieties about change.
Unfortunately, the perception of secrecy which arose as a result of this served to fuel anxieties as much, if not more, than a process of sharing plans might have done. In some areas it also drove a rift between NHS leaders and their local authority counterparts, with a number of councils publishing draft plans citing explicit concerns about transparency and public accountability (Bunn, 2016).
Although every area has now published its draft plan, the damage has already been done. Reporting on the results of its enquiry into integrated care, the Health and Social Care Select Committee (2018) noted that “Sustainability and Transformation Partnerships (STPs) got off to a difficult start, with limited time to forge relationships, develop plans and make difficult decisions about changes to local health and care services. National media coverage of ‘secret plans’, ‘developed behind closed doors’, reflected the poor communication between local bodies and their communities. This, along with accusations that STPs were a smokescreen for cuts, tainted the STP brand.” Many of the recommendations in the report focused on the need for better communication and engagement with the wider public.
But there are some good examples of areas which are setting out to take a different approach, often building on the experience of local authorities.
The Healthier Wigan Partnership (2016) has developed a ‘Deal for Health and Wellness’ which forms part of a suite of ‘deals’ developed by Wigan Council with local people. The deals are rooted in transparent and ongoing conversations between local leaders and the wider public about the challenges faced by the public sector, and the needs and wants of local communities. To date, the ‘Deal for Health and Wellness’ covers relatively uncontroversial topics largely relating to the prevention of ill health. But under the umbrella of the Healthier Wigan Partnership, a ‘Shape Your NHS Community’ group has been formed, enabling residents to participate in all stages of discussions on service change. Time will tell as to whether this approach will allow us to avoid the pitfalls of the past as we embark on the service changes the essays in this collection discuss.
Barrett P (2012) Safety, Sustainability, Accessibility – striking the right balance: Reflections of a retiring Chair. https://www.gov.uk/government/publications/safety-sustainability-accessibility
Bunn J (2016) ‘Second 'full' STP published as council hits out at process’. HSJ, 24 October. www.hsj.co.uk/sectors/commissioning/second-full-stp-publishedas-council-hits-out-at-process/7012767.article
Cowper A (2018) Suspicious minds: public perceptions about changes to NHS buildings. NHS estates: viewpoints. Nuffield Trust. https://nuffield-trust-nhs-estates.squarespace.com/article/2018/1/8/suspicious-minds-public-perceptions-about-changes-to-nhs-buildings
Gainsbury S (2011) ‘Panel advises closing Chase Farm A&E’. Financial Times, August 17. https://www.ft.com/content/3e84f052-c8ef-11e0-aed8-00144feabdc0
Health and Social Care [Select] Committee (2018) Integrated care: organisations, partnerships and systems. Seventh Report of Session 2017–19. https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/650/650.pdf
Healthier Wigan Partnership (2016) The Deal for Health and Wellness. Wigan Council. www.wigan.gov.uk/Council/The-Deal/Our-Deals/The-Deal-for-Health-and-Wellness.aspx
House of Commons Select Committee (2007) Session 2006-7: Health – Third
McKevitt C, Ramsay AIG, Perry C, Turner SJ, Boaden R, Wolfe CDA and Fulop NJ (2018) ‘Patient, carer and public involvement in major system change in acute stroke services: The construction of value’, Health Expectations 21(3), 685-692. https://onlinelibrary.wiley.com/doi/full/10.1111/hex.12668
Buckingham H (2018) "Lesson 2: Listen to the public – and don’t pretend you will if you won’t", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/lesson-2-listen-to-the-public-and-don-t-pretend-you-will-if-you-won-t