Reconfiguration versus re-election: public expectations and health reform

Clinicians and health service administrators can often identify ways of reconfiguring services, particularly hospital services. These reconfigurations usually appear to deliver improved outcomes but prove hard to sell to a sceptical public. On these occasions, local politicians are urged to be brave and support such moves.

All too often though, the politician is found fanning the flames of popular discontent and those inside the NHS look upon them with varying degrees of sympathy, bewilderment, despair or contempt. The situation is actually made worse if health insiders believe that politicians privately understand the case for change but publicly resist it.

Politicians have a primitive instinct for survival and from Kidderminster to all places north, south, east and west they know that there is no future for an MP or councillor who fails to respond to public alarm about hospital services.

Bravery is one thing; foolhardiness is another. Anyone who has felt the heat of a ‘save our hospital’ public meeting can testify to this. Even if the politician is prepared to be ‘brave’, he will soon have potent rivals who will damn his bravery as supine acquiescence.

Until the NHS comes to terms with access and expectations of access and is prepared to listen to the voice and expectations of the public, plans hatched will tend to be scotched by public opinion

Clinicians, on the other hand, are generally not up for or used to rough questioning from the general public. It is naive anyway to suppose that local clinical opinion is unanimous; it rarely is – which leaves ‘brave’ politicians still more exposed.

To understand all of this properly the focus should not be on the behaviour of the politician but on the underlying dynamics. The public have a nose for financial or institutional pressures and can readily see that the good clinical case is not just a good clinical case.

They also may not share the mindset of clinicians in the way that clinicians feel they should. They value proximity and access as well as quality of service, and are prepared to consider trade-offs between them.

To put it bluntly, the public simply want their way. If the hospital or the hospital unit cannot be both in A and in B, don’t expect the inhabitants of B to be reconciled readily to it being in A or the honourable member for B to say so. Nevertheless, I don’t think the public are quite as unreasonable as clinicians and hospital chiefs often suppose.

They will travel to the ends of the earth to get life-saving treatment and a high quality intervention, but they sensibly see no need to travel far for basic triage or first-base treatment. They carry around in their heads a notional idea of the distance they must travel for medical reassurance. In my constituency, cancer patients travelled without complaint right across Merseyside to the Wirral.

Yet the town was outraged when a reconfiguration meant that children suffering accidents had to be triaged just eight miles away in the next town. Clinicians have no such maps in their heads. They tend not to use local buses and regard roads as a purely council matter. They know roads can be a problem – but not an NHS problem.

Until the NHS comes to terms with access and expectations of access and is prepared to listen to the voice and expectations of the public, plans hatched will tend to be scotched by public opinion. There won’t be the political will to see them through. And, arguably, there shouldn’t be.

Dr John Pugh MP is Co-Chair of the Liberal Democrats Parliamentary Policy Committee on Health and Social Care. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.

To read further reflections from parliamentarians on the recent NHS reforms, download a joint report from the Nuffield Trust and The King’s Fund: The view from Westminster: Parliamentarians on the future of health and social care (June 2013).