The public is wary of the changes facing the NHS but local citizens can be won over if they are encouraged to contribute towards shaping health services early on, say Robin Clarke and Deborah Rozansky
Health service reconfigurations are nearly always controversial. Closures, mergers and the reorganisations of hospital services are viewed with understandable suspicion by patients and the public, who often mobilise to defend the status quo in the face of what they perceive as cuts.
However, to quote from an open letter from the Royal College of Surgeons, Royal College of General Practitioners, the NHS Confederation and others: “No change is not an option.” The question then is what type of change to service configuration will ensure available resources are used to achieve the best care for patients?
‘It is the job of engagement and consultation teams to make sure the reasons behind opposition are understood and considered’
From our experience of working on the Better Services, Better Value programme in south-west London and Epsom, and Shaping a Healthier Future in north-west London, the changes to service provision that are likely to work best are those that take into account the views and suggestions of local people and patients.
This is of course not to say there won’t be campaigns against reconfigurations but, away from the raised voices and marches, there is potential for more meaningful dialogue between the public and local healthcare commissioners, provided it is well planned, starts early and is sustained.
Engaged in change
The purpose of engagement work is to hear the views of all those concerned and affected by proposed changes. As can be expected with changes as substantial as a hospital reconfiguration, there are often groups and individuals who vociferously express opposition to the reorganisation of services − it is the job of engagement and consultation teams to make sure the reasons behind their opposition are understood and taken into consideration.
However, typically there is also a larger, less vocal majority, who tend to say little publicly about planned changes. It is vital that these people are also engaged and, because of their timidity, doing so usually requires more work.
When engaging with patients and the public on service reconfiguration, the first thing that must be made clear is that the process is not a referendum. Engagement that ultimately makes a difference to changes made to service provision does so because it accepts some form of change needs to take place.
‘It is worth remembering how rare it is for a decision to go out to formal consultation and come back in the same form as it started’
Therefore, when consulting, the parameters of dialogue are set so conversations do not focus on “if” services should change, or indeed “why”, but “how” provision can be reorganised to better meet our needs in future.
Much of this work happens in the pre-consultation phase when the purpose of engagement is to make the case for change, explaining why there is a need for change and checking the public agrees. This is the time when commissioners should set out their vision for the future.
In the formal consultation phase, which usually lasts 12-14 weeks, the public is asked to review − and hopefully improve − on proposals.
It is also worth remembering just how rare it is for a decision to go out to formal consultation and come back in the same form as it started. This is an important message for commissioners to communicate to the public throughout − their opinions have a profound impact on policy.
For example, the ongoing Better Services, Better Value programme, a service review covering five hospitals in south-west London and Epsom − Croydon, Kingston, St George’s, St Helier and Epsom − saw clinicians and those who support them attend more than 100 meetings with local people in the pre-consultation phase over an 18-month period. These included conversations with local community groups, public meetings, drop-in information centres and more formal presentations.
‘As a direct result of feedback from the public, a number of changes to the proposed reconfiguration of services have already been made’
The feedback given at these events was reviewed by clinical leaders and many tangible adaptations to the clinical models were made as a result. One response from the public was that major operations and day surgery should be available seven days a week and at flexible hours. Since receiving this feedback, the planned care clinical working group said they expect to extend the usual hours of working in theatres to 12 hours a day, six days a week, which is a 44 per cent increase.
Change in action
Feedback on end of life care proposals also had an impact, with greater emphasis now being put on accepting changes in patients’ individual wishes over the course of their illness.
For example, while there are many people who express a wish to die at home, some of these patients may decide over the course of their illness they would prefer to die in hospital; there was recognition that this option should still be available to them.
The reconfiguration of services in north-west London has progressed further than Better Services, Better Value, having already passed the formal consultation phase. As a direct result of feedback from patients, the public and others, a number of changes to the proposed reconfiguration of services have already been made.
‘If we want to see health outcomes improve, there does need to be some significant reconfiguration of services’
A common urgent care centre specification has been developed, for instance, which − among other things − sets out what conditions should and should not be treated at the various sites. There has also been an agreement to delay the implementation of the hospital reconfiguration from three to five years, and detailed work around the implementation planning for out of hospital service provision remains ongoing.
One of the main concerns for almost any reconfiguration programme is the travel implications of any changes. Public responses highlight that people trust their own experience over published data, especially where complicated formulae have been used to calculate average travel times.
In north-west London this has led to additional travel analysis work being undertaken, including:
- exploring the implications for public transport, walking and cycling journey times;
- the eligibility criteria for travel concessions for patients and whether this can be standardised across north-west London; and
- the impact of proposals on parking capacity, blue badge holders and step-free access within the Transport for London network.
The public’s acceptance or rejection of most reconfigurations can be distilled into one single question: are people prepared to travel further for better quality and safer care? If people can be convinced that their health outcomes will be better after the reconfiguration, and they trust that the travel information they receive for the future is accurate and includes steps to mitigate any potential impositions, then the battle to win hearts and minds is made much easier.
In these, as in all reconfiguration programmes, it is true the financial imperative to save money has an impact. This fact needs to be acknowledged and explained in the engagement and consultation exercises that take place. It is important people understand that by looking at costs, money can be reinvested and used in ways that have a greater impact on patient outcomes.
There is growing realisation and acceptance among the public that some of the larger problems faced by the health service require solutions more drastic and fundamental than simply an increase in funding. The fact of the matter is, if we want to see health outcomes improve, there does need to be some significant reconfigurations of services.
Our experience suggests the public is very wise and honest dialogue is possible; people generally accept that care must improve but that public resources are finite and should not be wasted. The process of engagement, if done well, can ensure local citizens contribute meaningfully and tangibly towards shaping the future of their local health services.
Robin Clarke is engagement and consultation lead and Deborah Rozansky is head of the health and social care team at OPM