Meeting the public everywhere from scout huts to traveller sites has been a vital component of modernising provision in Hertfordshire. Nick Carver and colleagues explain.

Health systems working together can achieve consensus on contentious service reconfiguration proposals. All NHS trusts need to ensure they can provide clinically, operationally and financially sustainable services in the context of constant technological change. Better drugs, expanded community services, new technologies and improved surgical techniques are all helping to improve quality of life, extend life expectancy and make healthcare more convenient for patients.

The pace of this change is getting quicker and as we learn more and develop better procedures the structure of health services will need to change. The challenging economic environment means all acute trusts must demonstrate whether they can be commercially sustainable as foundation trusts while providing high quality services.

For the last 20 years the NHS in Hertfordshire had consistently failed to reach a consensus about the best way to radically overhaul acute service provision – something which was needed to ensure the future quality, sustainability and efficiency of local inpatient and emergency services.

Despite some initial local opposition, consensus was finally achieved in 2008 following an extensive engagement and consultation process known as Delivering Quality Healthcare for Hertfordshire.

There were some key elements to success in achieving consensus.

Clinical leadership

Clinical leadership drove clinically led proposals. Senior clinicians led the case for change and were central to pushing the reconfiguration forward. Clinical leaders across both primary and secondary care wanted to ensure clinically sustainable services for the future. Having clinicians leading the reconfiguration was also vital to setting out the critical importance and benefits of service change to the public. They were able to explain that reconfiguration would improve clinical safety and patient outcomes, use the skills of specialist staff more effectively and provide the basis for sustainable services.

East and North Hertfordshire GP Commissioning Consortium chair Tony Kostick says that the consultation was about “providing more care locally in the community”.

Dr Kostick explains: “Our end point was that only those who really needed specialist hospital care would need to go to there, while at the same time those who traditionally had to go outside of Hertfordshire for some types of treatment, especially around cancer and cardiology services, would have them provided through their new acute hospital. It was, and remains, the blueprint for health services in the county.”

East and North Hertfordshire Trust medical director James Quinn agrees.

“Too many of my colleagues, both doctors and nurses, found themselves supporting services that were spread too thinly across two hospital sites that were both no longer really fit for purpose,” he says. “Twenty years of inaction had led to little real investment at a time of great change elsewhere. While some of us may have held private preferences as to which of the two hospital sites was chosen for redevelopment, all of us both supported and articulated publicly within our local communities the clinical case for change.”

Original purposes

What the Delivering Quality Healthcare for Hertfordshire consultation proposed in 2007:

East and North Hertfordshire Trust

  • Centralisation of inpatient and emergency services at either QEII Hospital in Welwyn Garden City or Lister Hospital in Stevenage

East and North Hertfordshire PCT and West Hertfordshire PCT (now a single organisation called NHS Hertfordshire)

  • The commissioning of two local general hospitals to provide substantial centres of care for communities in Hemel Hempstead and one of either Welwyn Garden City or Stevenage;
  • The establishment of a county-wide network of urgent care centres to provide emergency care access for about two thirds of patients who currently attend accident and emergency

Working together

The proposals were visibly supported by the boards of both of the primary care trusts in the county as well as the hospital trust. Executive leads were appointed by each organisation to work together in managing the engagement and consultation process, a programme board ensured effective collaboration and working and a joint consultation and communications project team ensured successful pan-organisational efforts.

PCT chief executive Jane Halpin says that one of the hallmarks of success was the approach to communication and engagement.

“We brought our clinicians and senior managers out to where people were already – everything from scout huts to travellers’ sites, we engaged people out in the community and not in the boardroom. It was an approach that worked, as well as one that was appreciated by those scrutinising our consultation processes.”

Public engagement

The team leading the reorganisation built on a strong track record of public engagement. A two month discussion period preceded the formal consultation. All engagement was based on a double-act approach with both acute and primary care representatives present. We found spending time with our communities and their leaders to be a rewarding experience; consultees were open minded and more than capable of understanding major issues.

The ethos throughout consultation was to meet every request to attend a meeting and respond to – and document – every question we received. This enabled the team to engage with people across the community, including hard to reach groups.

In 2008, Hertfordshire county council was Conservative led at a time of a Labour government. In addition, the Lister hospital in Stevenage lay within a Labour MP’s constituency while Welwyn Garden City’s Queen Elizabeth II Hospital was in a Conservative constituency.

The trust’s chair and chief executive have held regular meetings with local MPs, council leaders, prominent local politicians and the local media. This helped to build up strong working relationships both before and during the consultation. This work served to both engage MPs on local NHS issues, as well as allowing the local NHS to keep up to date with political issues.

The NHS in Hertfordshire had also developed a strong relationship with the county council’s health scrutiny committee. There was a joint appreciation of the importance of proactively supporting effective scrutiny of the consultation proposals. Council officers and NHS staff worked closely together to make sure council members understood the complex issues facing the local NHS.

Hertfordshire County Council chair Bernard Lloyd, who was also chair of the health scrutiny committee at the time of the consultation, explains:  “As councillors, we were aware that health services locally needed to change. Our constituents were telling us that all services needed to improve, which was also the message that local doctors and nurses had been telling us for some time.

“We needed to get broad consensus about the clinical case for change, while recognising that not everyone would support all the proposals – especially the location of acute hospital services. We looked to the health service to provide us with the evidence that these proposals were not just clinically sound, but had the support to be delivered.”

Public response rates

The map shows response rates for the 4,410 people who supplied a postcode when completing the questionnaire. Darker shades show areas where the number of responses per head of population was higher than the Hertfordshire average, while the lighter shaded areas have a below average response rate. The population figures on which this map is based are drawn from the 2001 Census. There are some responses from outside Hertfordshire, mainly from the Biggleswade area: there seems no reason to exclude these from the analysis since people from these areas can and do use services in the county.

Robust consultation

However effective engagement may be during a consultation, it is vital that the process itself is robust and complies with statutory requirements, to guard against being open to a judicial review. The 2007 consultation was planned and documented meticulously. This included a legal review of all draft consultation documentation and processes; getting patient representatives to “road test” consultation documents; carrying out a health equality impact assessment; and using an external academic agency to independently evaluate the consultation process.

The consultation team and trust boards were committed to taking on board feedback and to actually using it – rather than just noting it. This led to the decision to pilot two urgent care centres in East and North Hertfordshire in response to feedback about original proposals to provide a single urgent care centre. It is of note that the local “Save the QEII” campaign considered, but chose not to seek, a judicial review of the consultation outcome.

In Hertfordshire two alternatives to the status quo were outlined in terms of how to reshape acute hospital services. The NHS team stated a clear preference for consolidation of the hospital services onto the Lister site in Stevenage. They felt doing this meant they could maintain their commitment to transparency and reflect openly the views of the NHS boards that this was the better option. The decision also enabled staff to engage in the discussions and express their views. In total, 58 per cent of the hospital staff who responded to the consultation supported consolidation on the Lister site.

Across Hertfordshire the NHS sought every opportunity to keep communication lines open with those groups that voiced public opposition to the proposals. We actively encouraged open debate on the clinical, operational and financial implications of the proposals. These debates helped raise wider awareness of the real threat to the local NHS of doing nothing.

East and North Hertfordshire Trust chief executive Nick Carver says: “By seeking to engage, looking for common ground and keeping the debate on the issue of the clinical case for change, we ended up with a much more robust and adult discussion that helped, rather than hindered, the consultation and decision making processes.

“Critical to this was helping those opposing change to visualise the services that would remain in the Welwyn Hatfield area, by bringing key individuals on a tour of a nearby local general hospital that would be very similar to the one proposed through the consultation.”

The same fundamentals have helped ensure continuing progress. Clinical staff and public engagement has been important in developing a variety of different business cases to keep the service changes moving forward. Constructive political engagement is even more crucial if the NHS in Hertfordshire is to successfully implement future changes. Robust, open and clear public communication underpins the relationship with patients and residents across the county.

Consultation statistics

  • There were more than 160 events with patients, members of the public, community groups and other stakeholders;
  • Held more than 120 internal events where 1,400-plus NHS staff heard about the proposals and gave their views;
  • Held or co-hosted 22 public meetings/drop-ins attended by more than 800 people in total;
  • Held events in 32 different towns and villages across the county and in areas bordering Hertfordshire;
  • Received more than 6,000 completed questionnaires and approximately 300 letters and emails from individuals and organisations;
  • Had more than 6,000 hits on the consultation website;
  • Distributed 400,000 summary leaflets and consultation questionnaires and 3,700 full consultation documents;
  • Provided information that contributed to more than 140 news articles and letters appearing in the local press.