The New NHS, as outlined in the government's white paper, and February's green paper, Our Healthier Nation, demand new organisational relationships and the rebuilding of public confidence.
The emphasis is on listening to the public, regularly surveying patients' and carers' experience, and working in partnerships with external organisations to achieve more integrated care.
Lines of communication between management and staff, NHS organisations and local authorities and others will need to be open and well established to deliver any part of the new NHS.
So how well equipped is the NHS to tackle this agenda?
The answer from a survey by the Office for Public Management would appear to be not very.1 The survey, conducted last year, asked all health authority and trust chief executives in England to assess their strengths and weaknesses in internal and external communications.
More than half (I am checking response rate JL ) responded.
It followed up on a similar survey in 1994. A second survey last year examined the experience of communications specialists in trusts and HAs.
The 1997 surveys found:
46 per cent of trusts and 69 per cent of HAs had a specialist communications post.
Only 5 per cent of these were senior, director-level posts.
More than half of all communications managers were working single-handed.
Under a quarter of trusts and HAs had more than two people working in communications.
This compares unfavourably with local government where, apart from the smallest of authorities, the typical public relations department has between three and ten staff.
The typical NHS organisation spends less than£75,000 a year on communications, including staffing and non-staffing costs. HAs spend more (average£97,000) than trusts (£64,300), low compared with other organisations. The Audit Commission report, Talk Back - Local Authority Communication with Citizens (1995) found that among the 16 London boroughs it examined, only two spent less than£100,000 on PR while ten spent in excess of£200,000 and three spent over£400,000.
An Industrial Society survey, Best Practice - Employee Communication, published in 1994, found that organisations with communication budgets spent an average of£300 a year per employee on internal communications alone.
Some spent as much as£2,000 a year.
If a typical trust of 2,000 employees spent£300 for each employee, its budget would be£600,000 a year, ten times what is being spent at present. This suggests the NHS is underinvesting in communications and low investment must limit the expected return.
While slightly more than half of all NHS organisations have a specialist in post, distribution varies between regions. Trent and South Thames have the most overall (around two-thirds of trusts and HAs) and the North West (around a third) the least (see table 1).
Most hold communications manager posts. A further one in five hold more junior posts such as communications officer, press officer or public relations officer.
Almost half (49 per cent) of communications managers work alone and more than half (61 per cent) earn£30,000 or less (see table 2).
Almost 70 per cent of communications managers have responsibility for both internal and external communications. Under 5 per cent are responsible just for internal communications.
Workload Most communications managers spend the bulk of their time on press releases and media relations, and working on both internal and external publications (see table 3) . Most in the survey agreed that they should devote more time to planning, strategy development and evaluating the effectiveness of their organisation's communications. Many believed it would benefit their organisation if they had more time to devote to development.
Many said they felt hampered by a narrow interpretation of their role. They are expected to function as technicians, 'cranking the handle' of communication when required.
They felt too little time was allowed for working alongside other managers, clinicians and staff to help them improve their communications. They also complained about being asked to do too much, too late.
Rather than being seen as an integral part of everyone's duties and responsibilities, communication was 'compartmentalised' and given to a single person to 'do'.
There are issues to be tackled about who should be doing the communicating and whether the right approach is being used.
There seems to be an over-reliance on posters, newsletters and videos and not enough on holding briefings and facilitating face-to-face discussions.
Many more trusts and HAs say they now have strategies for both internal and external communications (about 70 per cent) than four years ago (50 per cent or less).
HAs, in particular, have put a lot of effort into planning strategies in the last four years.
Most of those who said they did not have a strategy for internal or external communications are planning to develop one in the near future (see table 3).
Much as in 1994, the priorities for internal communications identified by chief executives were to develop systems and skills in order to explain objectives to staff.
The latest survey also revealed managers' growing recognition of the importance of communication in relation to change. Many more now recognise that successful implementation of change requires not only regular staff briefings, but involving staff in dialogue about how these changes will happen.
Respondents said of external communications that their priorities, as in 1994, were to promote an understanding of aims and strategies and to build a strong identity and reputation in the wider community.
There was greater recognition of the need to use good communication to build effective relationships with other agencies.
Chief executives in both HAs and trusts regard involving the public in decisions and encouraging feedback from service users as more important now than they did four years ago.
More chief executives now believe that their communication with most audiences is more effective than in 1994. The main exception seems to be with the wider public. Many chief executives view this as a key weakness (see table 4).
Chief executives believe their organisation's main strengths are openness and honesty, the ability to present consistent and coherent messages to different audiences and the use of clear and plain language. The main perceived weaknesses were the ability to get the right message to the right audience at the right time, and the ability to listen to and consult others.
Key problems On the whole, the same internal communication problems as four years ago are evident today.
These involve difficulties over consistent communication with staff who are often geographically spread out; complex issues; time pressures; staff resistance to change, and managers' poor communication skills.
For external communications the main problems appear to have changed from difficulties with handling the media in 1994 to organisations' attempts to communicate more directly with public, or tensions in their relationships with partner agencies. This is especially true of the HAs.
Although chief executives felt there had been an overall improvement in internal communications and communications with key partner agencies, relationships with the public remained as much a challenge as in 1994.
The number of HAs and trusts which say they have communication strategies has certainly risen. But there appears to have been little rise in resources to realise these strategies.
While most HAs and, to a lesser extent, trusts employ someone to fulfil the role of communications specialist, this is still generally a post whose responsibilities are to provide products, such as newsletters, annual reports and press releases, rather than offer strategic advice and facilitation. In most cases the postholder is relatively junior, with limited access to strategic thinking, and frequently has other responsibilities as well.
Many staff reported a sense of frustration and isolation - frustration that the weight of the reactive workload - dealing with media calls and producing briefing material - left little time for more proactive work and prevented them from working more closely with others in their own organisation.
The contribution of communications to effective healthcare is still ill-understood. Compared with best practice in other sectors, such as local government, the NHS puts significantly less money into both internal and external communications.
It appears that the present level of investment in communication in the NHS is woefully inadequate - or adequate only for a very limited set of objectives, certainly not the government's vision of the future NHS.
Its present commitment to developing communication in the NHS seems to be more tacit or emotional than actual.
Developing meaningful communication will require a substantial investment in appropriate training and development. This is investment of a different type from the spending on glossy publications which many people feel is a waste of public money.
Investment in people to improve the way they communicate should be seen as an investment in the quality of healthcare.
Often communications staff are appointed with too little experience, organisational know-how and credibility to take on a strategic role. If specialists are really to help the whole organisation to improve, they should be acting in many roles, including adviser, trainer, facilitator, ambassador, spokesperson, copywriter and 'firefighter' responding to crises.
Some current staff can and should be encouraged to develop their skills to take on several of the above roles. But it is unlikely that a single person could undertake them all.
A reconfiguration is likely to be necessary, possibly with a more senior appointment and additional senior professionals to take on the more strategic, advisory roles.
Major service reconfigurations and the work on health action zones, health improvement plans and the creation of primary care groups will necessitate a lot more cross-organisational facilitation. Having lead communications people working across organisations could have major advantages.
The agenda that the white paper and the green paper are calling for will require managers, professionals and other staff in trusts and HAs all to work at improving communications.
At present work on this wider agenda tends to be fragmented. Pockets of good practice exist but there are few real, across-the-board initiatives to make the necessary changes.
There is a major potential shortfall between present practice and future needs, especially in terms of communicating with the public.
If trusts and HAs are serious about what many of them have written into their strategies, they must accept the major implications. It is not enough just to appoint appropriate people. They must have clear roles, responsibilities and authority, access to information, regular contact with key people, a role in the decision-making forum and assurance that their advice will be taken seriously.
If commitment is to be more than tokenism, appropriate investment of money and time will be needed. And there must be a willingness to change attitudes and behaviour.
It cannot be left up to medical schools to change their curriculum or to individual managers to work on communication as part of their personal development agenda.
If the development of communications is really going to be a critical part of the new NHS, real commitment from trusts, HAs, the NHS Executive and ministers will be needed.
Comments from survey participants
'A communications department of one person cannot adequately communicate with all external audiences. I feel I am fire-fighting all the time, even though we have an agreed strategy' Trust communications manager
'Lack of resources mean external communications tend to be unplanned, rushed and sometimes cheap and cheerful' Trust communications adviser
'Communications is the least well-served area, in manpower, resources and regard by colleagues.' Health authority communications officer
More than half of NHS organisations now have a communications post.
Almost half of all communications managers are working single-handed.
Most earn£30,000 or less.
The typical NHS organisation spends less than£75,000 a year on communications, notably less than many local authorities.
The present level of investment in communications is woefully inadequate to deliver the new NHS envisaged by the government.
1 Lloyd P. More than Lip Service. A survey of communication practice in the NHS. Office for Public Management, 1988.
Helen McCallum is head of communications at the NHS Executive. Paul Lloyd is fellow, Office for Public Management.