Surrey and Sussex has opted for a prolonged period of public consultation on its extensive - and controversial - remodelling of services. But has the approach made managers' work any easier? Alison Moore investigates

Surrey and Sussex has opted for a prolonged period of public consultation on its extensive - and controversial - remodelling of services. But has the approach made managers' work any easier? Alison Moore investigates

Like many NHS communities facing a tricky reconfiguration, Surrey and Sussex has embarked on a 'softly-softly' approach to public engagement.

When plans finally go out to consultation some time in the new year, it will be at least 12 months since the launch of a 'first steps' document analysing the requirements of services across the community was published. A second document, aimed at a wider audience, followed in May.

This extensive period of pre-consultation 'stakeholder engagement' is becoming increasingly common for areas facing difficult changes.

But prolonged debate in the absence of firm proposals creates its own dangers, suggests one local manager, who says 'myths and legends have grown to fill the gap'.

In Surrey and Sussex, speculation has dominated the local media for most of this year. With the NHS in the area overspending by£100m a year, one 'nuclear option' is thought to be removing acute services from two major district general hospitals - possibly Royal Surrey County in Guildford and St Richard's in Chichester - and downgrading those in Crawley, Haywards Heath and Shoreham.

'Save our hospital' campaigns have been launched in several towns and this autumn thousands of people have demonstrated - 5,000 in Guildford, up to 10,000 in Worthing, and more than 40,000 signing a petition in Haywards Heath, with an overnight vigil planned for next month.

The protestors have not been short of big-hitters either - if the area's MPs are not going to light your fire, celebrity protesters include Sir Paul McCartney, comedian Jo Brand, artist Alison Lapper and housewives' TV favourite Des Lynam.

Opponents of change will have been able to organise and influence the media for nearly a year before the proposals finally become public. Michael Foster, Labour MP for Hastings, said early on that 'pre-emptive strikes are sometimes appropriate and prevention is better than cure.' Anne Milton, Conservative MP for Guildford, says: 'The biggest opportunity we have to make an impression is before the consultations start.'

Much of the early engagement underlying the Creating an NHS Fit for the Futureprogramme has been condemned by campaigners and the press as 'behind closed doors'.

Yet, inevitably, many of the scenarios leaked into the public arena - including a presentation to strategic health authority board members in March which MPs claim show an 'emerging viewpoint' that Worthing, St Richard's and the Princess Royal should lose services.

'They decided not to go out to the general public at an early stage but to phase it, starting with consultants and MPs,' says one source close to the process. 'They listened to what they had to say - then went out and talked to newspapers and put it on websites. There have been so many hares off running, it is very difficult to draw it back in.'

Since May the public has been more involved through a discussion document to which they can respond, public meetings and workshops.

The PCTs involved stress that they are listening to what is being said - and what is happening now is a long way from the old-style NHS methods of only involving the public once decisions were all but made. Instead the health community has been honest about what the problems are, and has listened to suggestions from the floor. 'Our approach has been to start with the issues and develop our thinking in public with the help of staff, stakeholders and local people,' says West Sussex primary care trust.

Jill King, who is leading the project in Surrey, says plans have been modified as a result of stakeholders' comments - for example, dropping a single telephone number for unscheduled care. The process has also given the NHS an insight into how patients experience healthcare, she says.

NHS South East Coast says that when it takes people through the issues and allows them time to reflect, they can see change is needed.

But this is a time-consuming process and is likely to involve only a fraction of the population.

The backdrop of growing financial pressure on the NHS over the summer, with Surrey and Sussex in the spotlight, has not helped. Only last week the SHA wrote to NHS organisations warning that they were overspending even against the agreed£94m control target.

This means the debate about healthcare redesign has been seen to be about saving money rather than necessary and beneficial changes.

Selling community services as a preferable alternative to hospital-based services is never easy - but doing it when so many people perceive it to as a cost-cutting measure is doubly difficult.

And some campaigners argue that, despite the best efforts of the SHA and PCTs to argue that this is an 'all options' review, the NHS has known what it wanted to do all along. This perception was strengthened last week when East Sussex Hospitals trust announced it wanted to close one of its maternity units next year. Only the appearance of unexpected options in the final consultation is likely to change this perception.

While doctors are backing changes in some areas, that is not universal. In Hastings and Eastbourne, some leading clinicians have been arguing for a merger of maternity services. However, in Worthing there has been strong opposition to any downgrading from doctors and nurses, and some feel disengaged from the process.

Cardiologist Dr Mark Signy says there has been little consultation with clinicians about the plans, emerging proposals have not been clinician-led, and some of clinicians' alternative proposals are not being taken forward.

As the consultation timetable has slipped, the lack of firm proposals is causing some concern: in September a staff briefing for NHS workers in the region laid down some 'emerging options', but NHS managers acknowledge that patients and staff are having a difficult time as they wait for the final options.

Bob Lacey, chair of East Sussex health overview and scrutiny committee, says: 'I don't understand why we have still not been offered options about what might happen. It is all very well to say there might be change, but at the end of the day we need options.'

Are there lessons to be learned for other consultations? Dr Signy suggests that Surrey and Sussex should be 'a case study in how not to do it'.

'Always engage with clinicians before you put anything in the public eye,' he says. 'They have managed to antagonise the clinicians at Worthing, Southlands and Haywards Heath before they put anything out.'

Some health service managers in the area are known to have expressed disquiet about how the process has gone so far. With changes to the SHA and PCTs, new chairs and chief executives have wanted to know what is being considered, and why, before they commit themselves: this is thought to be one of the reasons that the consultation timetable has slipped. However, local MPs say the NHS is 'edgy' and 'defensive' - caught off-guard by the strength of resistance.

But those close to the proceedings say there are positive lessons. Jill King mentions the use of external facilitators; feedback of responses to questions raised at meetings and showing that points raised influence planning; and tape-recording meetings to ensure that responses are made to all points.

Ensuring key stakeholders are 'alongside' is also important - but she concedes that getting clinicians engaged has some way to go. In some areas, there is cynicism about the process - possibly the legacy of difficult consultations in the past, she says.

NHS Confederation deputy director of policy Jo Webber declines to comment directly on the Surrey and Sussex position, but says health economies should try to engage the public from the word go. 'Once you are speaking to local councillors and politicians, it will get out into the public domain,' she says.

'The public and the stakeholder consultations almost need to run side by side so they feed on each other. Local media, local councillors and local MPs are crucial if you are looking at change. To be open and say &Quot;these are the options we are looking at&Quot; at least starts the debate and puts it into the public domain.

'But we have to get better at engaging people throughout the process and not just when we have to make a difficult decision.'

The political price of service changes

The critical question remains: does the NHS have the resolve to push forward with unpopular reconfiguration - and will it be backed by the government if it does?

Surrey and Sussex are Conservative strongholds with just five Labour seats - Crawley (where the hospital has already undergone a downgrading process), Hastings (where the accident and emergency department appears to have been saved) and three seats in the Brighton area. Brighton is, of course, the big winner in all of this, seen as the natural place for many acute services.

This makes it relatively low risk for the government in terms of losing seats. However, the timing of the consultation is becoming ever more difficult.

Start later than the early days of January, and the May local elections will fall right at the end of the consultation period. Leave it later and it could get caught up in pre-election fever and the Blair resignation.

'The time for action is always in the first 18 months of the political cycle,' says one insider.

NHS chief executive David Nicholson has signalled that he will back tough decisions. But the job of implementing them falls to local managers, who may find the public opprobrium harder to bear. 'It's going to take toughies to do this,' says one commentator. 'Nicholson may be tough but how many other people are prepared to stand up and say this hospital is going to close?.

But if the government - and the NHS - can ride out the storm in Surrey and Sussex, the lessons learned may help other areas find calmer waters.