The problem with transformational change in the NHS is that it generally involves closing or cutting something. The public is increasingly aware that the NHS is under pressure and that funding has become a really big issue.
In a recent IPSOS Mori poll for The Health Foundation, nearly nine out of ten respondents said they wanted to see the NHS protected from “any cuts” – a far higher proportion than for any other area of public spending, including defence, policing and schools. In that context, it is perhaps no surprise that people will tend to oppose plans for cutting beds and closing hospital departments.
But resistance to major service changes is not new. As far back as the 2001 general election, Richard Taylor – a doctor – won a famous victory, unseating an incumbent MP on the back of his campaign to restore an A&E department to Kidderminster Hospital.
Kidderminster might have been the grand-daddy of all ‘save our hospital’ campaigns. But it is only the more prominent of a long line of local campaigns against major service reconfigurations.
The Kidderminster effect has required NHS leaders to wise up about communication and engagement. The general principles are well accepted. If you want to take me on a journey of change, you need to involve me from the outset, you need to speak my language, you need to explain your case and you need to address my concerns and be prepared to change course.
You might have complex clinical, workforce and financial reasons for closing my local maternity unit. But I want to know how I am going to travel 30 miles to the next one, without a car.
Changing care, improving quality, a joint 2013 report from the NHS Confederation, National Voices and the Academy of Medical Royal Colleges, captures this wisdom and remains relevant. Healthwatch England has summarised similar thinking in five principles for ensuring that communities have a say in health reforms. This is not rocket science, but the NHS doesn’t always find it easy.
Recent work by the opinion researchers Britain Thinks for the Richmond Group of charities offers useful insights for those seeking to win public support for major change. They found that people are sceptical of cost saving as a rationale for change. They are also wary of negativity about growing “demand” – which can seem to blame people for being old and ill – and often alienated by the language of fundamental change, with its “transformations”, “revolutions” and “radical changes”.
But this is not just about better communication and engagement. NHS planners must beware of assuming that their case for change is solid, just insufficiently understood.
There can be a tendency for the experts to assume that the public is just wrong: sentimentally attached to “bricks and mortar”; irrationally prone to favour convenient access over safety; misled and inflamed by local politicians seizing a resistance campaign as a way to win easy votes. A good corrective to such thinking is the 2014 King’s Fund report, The reconfiguration of clinical services: what is the evidence?
In one of their more striking conclusions, the authors report:
“The reconfiguration of clinical services represents a significant organisational distraction and carries with it both clinical and financial risk. Yet those who are taking forward major clinical service reconfiguration do so in the absence of a clear evidence base or robust methodology with which to plan and make judgements about service change. In particular:
- Evidence to support the impact of large-scale reconfigurations of hospital services on finance is almost entirely lacking.
- Evidence on the impact on quality is mixed, being much stronger in relation to specialist services than other areas of care.”
That authors also note that: “Gaps in the evidence will often lead to different and sometimes conflicting views on the best way of providing safe, high-quality services within available budgets.”
Little wonder that the national bodies have imposed a new requirement on NHS planners, so that if they are proposing significant bed closures they must also demonstrate they have the alternative services, or workforce, or new technologies in place to make these plans work for patients.
The NHS is under huge pressure to live within its increasingly inadequate means, and to pursue big service changes which may or may not be sufficiently backed by evidence. The name of the game cannot be to cook up plans behind closed doors and then try to sell them to a sceptical public. Defining both the problems and the solutions has to be a partnership between professionals and the communities they serve.
This blog was first published on the NHS Confederation website on 5 June 2017.