Change is a sensitive issue. It is a truism that the NHS is our most cherished national institution (as a workshop participant once told me, “it is in the marrow of our bones”). This makes the public wary of anyone seeking to tinker with the system.
At BritainThinks, we often tell our clients that when trying to win an argument or debate, they should start from where their audience is, not from where they wish their audience were. If you assume knowledge, or start from the assumption that your audience share your values and priorities, then you quickly lose permission to speak.
On that basis, and in light of recent press coverage about Sustainability and Transformation Plans (STPs), it is helpful to consider how the public think about the NHS and the services it delivers, so that the NHS can consider how to address any issues where expectations are misaligned.
Sensitivity is exacerbated by the fact that the NHS has historically struggled to communicate change in a way that the public find compelling, as witnessed by the protests that can occur at the slightest suspicion of ‘privatisation’, let alone whenever the idea of closing a hospital is floated.
Access to the NHS is considered through the ‘frame’ of an emergency
Happily, for most people, their contact with the NHS is irregular and partial – perhaps a couple of appointments per year with a GP. Whilst they are aware of the wider system that exists beyond their experience, their understanding of that system is limited. It is often only when they or a family member experience a health crisis that members of the public begin to develop a more rounded sense of the service, and even then it can be a fairly ‘narrow’ experience of a single care pathway.
However, when we talk about the NHS in focus groups, participants often think about rushing to hospital with a sick child in the back of their car, or recall incidents when a loved one was close to death.
This makes access to the NHS a very emotive topic.
It also gives rise to a perception that time and distance are of the essence, and certainly more important than which hospital patients go to, or which doctor they see. Put simply, it does not feel right to most people that it could be better to travel further to end up at, for example, a specialist cardiologist unit, rather than a non-specialist hospital closer to home. Facts about the uplift in patient outcomes from going to a specialist unit struggle to cut through this emotional framework.
A lack of trusted spokespeople makes it hard for the public to assess the state of the NHS
Much has been written about the decline in trust in institutions, and this decline affects organisations that speak out on the NHS as much as those in any other field. Every word is scrutinised for any hint of an agenda or – worse – signs of ‘politician speak’.
When MPs are seen as being unwilling to speak honestly about the state of the NHS, and the media as sensationalist and ideologically driven, it becomes very hard for the public to filter what they are hearing and develop a clear picture of where things stand.
In contrast to MPs and the press, trust in individual health care professionals remains high. However, they lack the national perspective and, as mentioned, contact with them is irregular. And, even if they had the inclination to do so, few patients are likely to waste precious appointment time asking questions about the performance of the NHS.
Turning to the bodies that speak for the medical profession might seem like a solution. However, most of those organisations are unfamiliar to the public, and the impenetrable acronyms are hardly reassuring. And, despite trust in individual health care professionals, their representative bodies are assumed to have an agenda, just like with any other organisation.
Public concern about the NHS is growing
Whilst the messages that the public hear about the NHS are often treated with suspicion, the one piece of information that is getting through is that the organisation as a whole is in trouble.
Towards the end of 2016, we ran focus groups exploring perceptions of the NHS for the Richmond Group of Charities. In those groups, the public talked about seeing a system under increasing pressure, and we heard people starting to use the language of ‘crisis’ (although it is worth noting that some are very resistant to the word itself). In Ipsos MORI’s January 2017 Issues Index, 49 per cent of respondents said that the NHS is one of the biggest issues facing Britain today, a nine-point jump since December 2016, and its highest level since April 2003.
”Maybe you can say crisis… there are so many problems and how many can you fix? So you have to prioritise what’s important and what needs fixing first. And we’re not going to do that because the money is not going to suddenly appear.”Focus group participant
The public are worried about funding, staff shortages, the impact of immigration, a perceived decline in the caring ethos of the NHS, and the ability of the service to adequately meet the needs of an ageing population, to name just a few of the issues raised. Crucially, there is very little sense that anything is being done to address any of these.
There is willingness to consider change, but only if the motivation is to improve patient experience
Rising concern does mean that there is more openness to change than might otherwise be the case. However, the perceived motivations for that change are critical. In our focus groups, we were told clearly that the NHS should sit outside politics. Any sense that change was being driven by ideology – or worse – a desire to save money led to participants rejecting that change.
What this means for STPs
Change, then, will only be accepted if it is perceived to be motivated by a desire to improve care for patients and if the changes intuitively feel like they will deliver those benefits. Positively, some aspects of the STPs can deliver at least against the second part of those requirements. For example, when we discussed delivering care in the community with the public, this was welcomed as a positive improvement, which would be more convenient for patients. Whether planned reductions in hospital services can be communicated in a way that overcomes fears about travel times and distances remains to be seen.
Anastasia Knox presented at last week’s Nuffield Trust Health Policy Summit. A version of this blog also appeared The Guardian Healthcare Professionals Network, who were a media partner for the Summit.
Knox A (2017) 'Public perspectives on the NHS'. Nuffield Trust comment, 7 March 2017. https://www.nuffieldtrust.org.uk/news-item/public-perspectives-on-the-nhs