Building bridges

When Sir Ian Carruthers presented his national review of current reconfiguration proposals, he said its consistent message was that 'where change is well planned and well managed, it runs much more smoothly'.

And while he found that 'the good consultations were very good', the poorest performers were below the standard he would expect. Sir Ian said it was necessary to 'raise the bar' on the quality of local service consultations.

Given that change can all too frequently lead to a loss of public confidence in service, it is in everybody's interest that reconfigurations are carefully and robustly planned and managed, said the NHS South West chief executive in the February report.

He also said it was important to consider carefully the language used in describing change. 'Reconfiguration conjures up a whole host of images, not all of them positive,' he said.

'It has become a euphemism for closures and downgrading of hospitals...an entirely wrong impression of the schemes looked at over the past few months.'

Sir Ian said strategic health authorities, in their role as 'gatekeeper', must have a secure grip on what, when and why service proposals are being discussed in their area and ensure that primary care trusts make a clear, coherent and consistent case for change. Trusts themselves should normally lead the preparation and consultation on service improvement proposals, says the review.

As reconfiguration, change or service improvement means different things to different people in different areas, according to the
review, it concludes that each SHA will need a 'tailored strategy for consulting upon and managing change'.

Patients' needs first

The lessons and recommendations are grouped under the four themes of: effective organisational leadership and business processes; visible local leadership; open and honest stakeholder engagement, and delivery of results.

British Medical Association consultants committee deputy chair Dr Mark Porter says: 'We are very pleased that this report clearly states that patients' clinical needs must come first in any hospital reconfiguration plans.

'There also needs to be in-depth consultation with doctors and patients before any proposals are rolled out.

'Reassuringly, this report indicates that the aim of all reconfiguration should be to ensure that patients receive the best possible care.'

Listen carefully: Cornwall and Isle of Scilly

Cornwall and Isles of Scilly PCT's newly appointed chief executive Ann James's priority was 'engagement, not consultation'. Her aim was to listen to as many views of the local NHS as possible before putting forward any proposals.

And listen she did. Aware of a history of poor communication and lack of strategic direction in the health community, and of a public that was uncertain and restless about the future direction of the region's health services, she organised a series of public meetings, hearings, small group seminars and written questionnaires.

They included 12 Question Time-style events - and she attended all of them. But first, conscious of her unfamiliarity with the unique geography of the region which is responsible for unique healthcare challenges, she established an independent reference group (IRG) with an independent chair to act as a sounding board for the strategic review, called A Healthy Future.

Chaired by Nick Bosanquet, professor of health policy at Imperial College London and adviser to the Commons health select committee, the IRG included members of the health overview and scrutiny committees, district councils, patient and public involvement forums, League of Friends and special interest groups.

In January this year, at the end of the review process, that same group concluded that A Healthy Future had been 'robust, open and transparent'.

'I wanted the events to be about me as the new chief executive going out to meet the public and listening to what they had to say,' says Ms James, who was joined by members of the region's acute, ambulance and mental health trusts. 'We met with the public and stakeholders on their territory with a willingness to listen - it was wonderful going there with no specific proposals.'

Where possible, they chose existing meetings and venues to try to reach as many people as possible. To ensure those attending were aware of the context of the discussions, the trust put together a short document detailing the facts and figures of the services the trust provides with a broader outline of their future direction.

'We were asked everything from what happened to one patient's physiotherapist at one particular hospital to the future of cancer services to national funding formulas,' she says.

'The idea was to acquire a local community view of how the local health community world looked to them,' adds Ms James.

During this period of engagement, the chief executive made it clear that any substantial service changes which may have been planned would be suspended. 'Obviously lots needed to happen on a day-to-day basis in line with good clinical practice, but we did not want to make any premature decisions on long-term changes out of context.'

She also attended staff events within the trust and spoke at specially organised staff sessions at Cornwall Partnership trust, giving employees a chance to raise their own issues and aspirations.

At the same time, Professor Bosanquet was chairing select committee hearings - his independence providing an assurance and confidence in the process, according to Ann James. He was joined on the panels by NHS managers and board members.

'It was an excellent idea to have them there,' Professor Bosanquet says. 'I think being able to listen to the evidence produced by local communities helped them to a better understanding of the issues and to appreciate that often relatively small changes or actions can make a difference.'

The IRG received 'high quality' evidence at short notice from 42 different groups.

'Our aim was to achieve a buy-in to a long-term strategy - the basis for many operational plans - and we received that unanimous approval from the overview and scrutiny committee,' says Ms James.

She is retaining the group and its independent chair, with different terms of reference, to continue to work with the local health community and to judge the success of the delivery of the strategy. 'By maintaining continuity with the reference group and making sure the public has lots of information, we are on the threshold of slowly rebuilding confidence.'

What is essential now, she adds, is to take forward the strategic review, and to drive through and performance-manage the changes that have been agreed.

Professor Bosanquet goes further. 'There has been quite a welcome for the review and there is a feeling of optimism. I think Cornwall can now be taken off the blacklist.'

Conflict zone: Calderdale and Huddersfield

Health secretary Patricia Hewitt gave the final ruling on the future of maternity services in Calderdale and Huddersfield after asking the independent reconfiguration panel (IRP) to review the controversial proposals, opposed by more than 40,000 who signed a petition.

She agreed that consultant maternity services should be moved from Huddersfield Royal Infirmary to join Calderdale Royal Hospital five miles away and that Huddersfield should provide midwife-led services.

Although the reconfiguration plans, which had been 'live' for five years, focused on a whole-system redesign, it was maternity services which were the most contentious during both the engagement and consultation phases.

Jo Bibby, project director for the integrated strategy, believes her appointment in January 2005 to work across Calderdale and Kirklees PCTs and Calderdale and Huddersfield foundation trust was an important step in moving the consultation forward.

The engagement phase involved putting together clinically led service improvement groups, sourcing members from different stakeholder groups and partner organisations to assess the services that could not remain as they were. Primary care managers were also involved, displaying an understanding from the sector that the situation was unsustainable.

The engagement phase included a series of workshops, drop-in sessions and attendances at existing meetings, including mother and toddler groups, as well as public meetings.

Once the public consultation period for Looking to the Future began, a parallel scrutiny process became a valuable part of the process, ultimately highlighted by the IRP. It consisted of six three-hour sessions at which the PCTs and acute trust presented the evidence to the local authorities' joint health overview and scrutiny committee.

Ms Bibby says: 'This was an essential and valuable part of the process, where we had meaningful dialogue, covering a great deal of detail. It was a part of the process which felt very robust and reassuring.'

Huddersfield Central PCT professional executive committee chair Dr David Anderson, who represented primary care at many of the consultation meetings, agrees.

'The scrutiny meetings were out of the heat of the public campaign and gave time for the committee to ask very detailed questions and consider detailed analysis of the proposals. They were not just talking to us but to other people with different views. It was a very challenging position to go through.'

And in his report IRP chair Dr Peter Barrett concluded that the remaining disagreement over maternity services was 'approached with genuine concern, putting patients and their carers at the heart of the discussion'.

That confirmed the conviction of Martin de Bono, consultant in obstetrics and clinical director of women's and children's services for the hospital trust, who addressed many of the 100 public meetings. He says: 'This was not an individual campaign to try to revolutionise maternity services but a team who firmly believed that through reconfiguration we could actually improve a service.

'It was very important in both phases to ensure that all clinicians were signed up to what we were trying to achieve - for me that was one of our biggest strengths. Rogue elements in a team who do not agree can scupper the process.'

He says it was important to give details of the drivers for change, although explaining them to 'a passionate and emotional general public', backed by local MPs, was difficult.

'The passions and emotions created a lot of distraction at the meetings,' he says. 'But I think that drove us harder - there was as much passion from our team as from the public.'

Also key, he says, was to emphasise that the changes were clinically based. 'I am sure the public wants to know that these changes are not management based but driven by clinical need.'

Early groundwork pays off: Sandwell and Birmingham

Sandwell and Birmingham's strategy Towards 2010 sets out the long-term vision for one new acute hospital supported by five community hospitals and a commitment for 95 per cent of GP practices to be new or refurbished.

But because there are also plans to reconfigure some services in advance - the merger of four clinical areas which currently exist in two hospitals on to one site - consultation had to cover a wide spectrum of issues.

The process was jointly organised by Sandwell and West Birmingham Hospitals trust and Sandwell and Heart of Birmingham PCTs, with many consultation events attended by the acute trust's medical director Dr Hugh Bradby and Sandwell PCT PEC chair Dr Niti Pall.

Reflecting the importance placed by Sir Ian Carruthers' review on the need for clinical involvement at an early stage, Dr Bradby says: 'The original suggestions for reconfiguration were clinically driven, not in any way imposed on clinicians. There had been extensive discussions between clinicians in certain areas for a long time and all we have done is to take these discussions a stage further and introduce rigour to the process.'

Dr Pall says: 'In Sandwell we felt it was vitally important to inform local stakeholders and the public before the formal consultations began, because the changes planned are wider that just the acute hospitals reconfiguration, but involve out-of-hospital care, too.'

So the PCT held around a dozen pre-consultation events with the public and stakeholders, which, she says, gave local people a head start when the actual consultation began.

Over 200 public meetings were held, run jointly by the acute trust and the PCT. 'This is what really worked - having a senior person from each trust,' says Dr Bradby. 'The PCT representative spoke first, outlining the long-term plans, followed by the acute trust spokesperson, explaining what is going to happen in the meantime. Although some opponents cried foul and said it was muddled, I think it was coherent.'

Dr Pall says the meetings at which the audience were aware of the planned changes from pre-consultations were much easier than where the plans were being heard for the first time.

'There was some unease, particularly around accident and emergency, but we had to be open with the public,' she says. 'We had to explain that it is impossible to get from A to B without making changes in between.'

Explaining why changes were being made was also vital, says Dr Bradby. In his case, the reasons were very clear: producing a bigger clinical mass of specialists to work in teams developing specialties and offering treatments locally; to respond to recruitment and retention of doctors and health professionals who expect to work in larger, well-resourced units; and to avoid duplication on two sites.