Best practice: lessons from one of the UK's biggest consultations

Making It Better asked the residents of Greater Manchester, East Cheshire and High Peak what they thought of healthcare reforms for children, young people, parents and babies.

This six-year consultation was huge, covering 3.1 million people, 13 hospitals, 13 primary care trusts, 13 local authorities and 33 MPs. The services concerned - maternal, children's and neonatal - were emotive and the response rate unprecedented. Almost a quarter of a million people - 242,000 - made their views known.

The upside

The biggest strength of Making it Better is that it was driven by local clinicians. At first paediatricians took charge, then colleagues from maternity and neonatology joined them. They all agreed change was needed.

However, like most members of the local community, they were reluctant to name sites where change should happen. Most clinicians, barring a few individuals, wanted their unit to be part of an overnight site. Only a few put the survival of their own inpatient services at risk to argue that for the good of patients their hospital should become a less specialised daytime unit.

The sheer size of Making It Better was another strength. While the size made it complex, it was not about playing one area off against another, or compromising on effective clinical models to put 'something' in competing sites to keep local people and politicians happy. Small projects may be quicker and easier, but we delivered a new era in maternity, paediatric and neonatal care that benefits 3.1 million people,

Our unique clinical model was also an advantage because no hospitals close. All have a future, it is just that only eight will provide services round the clock, and only three of these will provide level 3 neonatal intensive care. The remaining hospitals will provide daytime services, with all areas getting significantly enhanced community services in line with what patients want and need.

This model allows us to:

• Meet NSF standards;
• provide care at home or closer to home, where clinically appropriate;
• meet royal college standards, such as all units having 60 hours of consultant labour ward cover and one to one.midwifery care for women in labour;
• be compliant with the requirements of the European Working Time Directive 2009.

The downside

Six years is a long time and a lot of work, however significant the decision. We 'survived' two NHS reorganisations but it was not easy. Each project became vulnerable as those around it reorganised and reprioritised. There were times when the confidence of our clinicians was low. They feared we would have to drastically change direction under a new set of managers.

The biggest difficulties have been time and money. The financial cost has been high. We have engaged local communities comprehensively and effectively, but this has taken significant resources, as has buying the legal advice and other specialist support the NHS lacks, for example communications and PR support.

Finally, there has been personal cost. Reconfiguration is seen as a threat and many people, including some clinical colleagues, fear for services they hold dear. Working relationships between those who champion reconfiguration and those who feel differently have become strained and have even broken down at times. We have been seen by some as saboteurs, delivering a message they do not want to hear. It is hard for people to hear that a local hospital is not as good as it should be, or worse. There are many willing to shoot the messenger, and this continues to be a battle.

What have we learned?

There are some simple lessons to come out of our six-year consultation:

• Clinicians are your greatest ally - if they are with you, or even better leading the project, then you can sway most people, even cynical politicians.
• Know your facts - analysis, analysis and more analysis. For example, we know more or less everything there is to know about our patient groups and how they use services. We have modelled that as many ways as possible. When decision day comes it will probably be too late to go back and find out anything you do not already know.
• Engage the local media - this is easier said than done, as it will almost always take a parochial view. Time and perseverance will yield results, however. One of the highlights for us was a headline in the Manchester Evening News the day after the decision saying 'Babies will live'. This contrasted with a headline two years earlier which said 'Babies will die'.
• Engage local politicians throughout - of course they will champion the local view in public, but if they understand the clinical issues most will privately support you.
• Do not underestimate nimbyism - some people will never agree to local 'losses', however many people outside their area may benefit. Be prepared for aggression, scepticism and cynicism. In Greater Manchester everyone lives within 30 minutes by car of a hospital which will have full 24-hour services, and most care will be provided locally if not at home. Yet even now some people will not accept a rare car journey to the hospital lasting 10 or so minutes longer in exchange for a gold standard of care. They all want to be near the 'super' hospital, and will not do the difficult job of deciding where it should be if it cannot be near everybody.
• Work with your joint overview and scrutiny committee but also individual OSCs - it is they who will refer issues to the health secretary. They have an investment in their local community so they will give you the time to explain your message and the need for change.
• Work with staff - the bigger the area and the more NHS organisations involved the harder this is. But it is a big benefit if you can get your message across to frontline staff, as they are the ones directly talking to patients.

Where now?

We are currently being reviewed by the independent reconfiguration panel. Life must go on, so we are now planning implementation.

Making it Better shows large scale reconfiguration can be achieved. It demonstrates that if we want a better future, we should not shy away from large-scale strategic change. In some cases, only a helicopter view of the needs of a large population will do. Our clinicians feel we have a cohesive strategy. It is not radical enough for some, but most can live with it. If we had approached reconfiguration in a piecemeal way we would not have been able to deliver such an equitable, consistent and workable solution.

There will always be people who are threatened by change. It is the role of NHS managers to enable the clinical champions to triumph - they will be here long after we have been reorganised.

Leila Williams is director of the Children, Young People and Families' Network for Greater Manchester, High Peak and East Cheshire

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