Originally published 14 June 2013. This article is retained from the tCI archive. Law, policy or practice may have changed since publication.
These are torrid times for those organising public consultations in the National Health Service. And the fallout from their experience will ripple through a wide range of other services where change is the order of the day.
Faced with almost daily allegations that corrode people’s confidence in Managers and Inspectors alike, a hapless Secretary of State appears regularly in Parliament having to explain away yet another embarrassment. None has been more dramatic than the unexpected suspension of the Safe and Sustainable review of children’s cardiac surgery in England.
The Rt Hon Jeremy Hunt had no choice. Despite £6m of taxpayers’ money, the process produced years of indecision, two judicial reviews and a final Report from the Independent Reconfiguration Panel that proved impossible to ignore. In short it said that the NHS proposals that led to the plan to end surgery Leeds, Leicester and the Royal Brompton Hospitals was “based on a flawed analysis of the impact of incomplete proposals.”
The Panel’s devastating Report highlights a range of failures, but the standout issue seems to be the scope of the project. Safe and Sustainable was set up to review Children’s Congenital Heart Services, but the thrust of much of the criticism was that one cannot look at this in isolation from the future of adult cardiac surgery. Given that it is often the same surgeons that treat adults and children/young adults, it was pretty obvious to many consultees that the overall picture of cardiac services would need to be considered. Unfortunately the NHS is said to have replied that “a line had to be drawn somewhere and that the alternative was to delay progress.”
No one – least of all laymen/women should assume that these are simple matters or easily-avoided errors of judgement. Such are the complex inter-dependences of modern services that it is very difficult to initiate a focused discussion on one aspect without the debate straying wider. Nothing frustrates stakeholders more than the sensation that consultors are trying to sidestep critical core questions by defining the scope of a consultation too narrowly.
Take, for example, the continuing controversy surrounding High Speed Two. Much of the anger stems from a desire to question the whole concept of a high speed train rather than discuss the precise route of the proposed railway. Many a controversy over planning permissions for wind farms, energy-from-waste plants or even airport runways is fuelled by campaigners denying the need for the facilities and reluctant to engage about proposed sites until that wider issue has been considered. One person’s safe assumption is another’s disputed pre-determination.
So, here is the dilemma. If major consultations are given too broad a scope, there is a danger that the argument ranges far and wide and fails to focus on those aspects that most need a constructive dialogue. If, on the other hand, the issues are too narrow, many of the contextual aspects will be excluded to the distress of consultees, and possibly to the detriment of good decision-making.
This is why the Institute places so much emphasis in signing off the ‘Scoping’ phase of a consultation when we undertake a compliance assessment. To meet our best practice standards we try to strike a balance between the need to focus tightly on those matters upon which the consultor organisation is open to persuasion and the reasonable expectation of citizens to discuss those aspects they believe to be relevant.
In many ways the right approach is to hold a sequence of consultations, becoming progressively more focused. In the case of waste management, for example, the theory worked rather like this. Major parts of the UK published formal consultations on the alternative ways of managing residual waste in their areas. The trouble was that few people even noticed. Only when decisions have already been taken, far away from the glare of publicity, and the next round of engagement revolves around specific sites, that the balloon goes up and the rows begin. A sequence-based approach only works if people are fully aware of what’s at stake right from the outset.
So, turning back to Safe and Sustainable, would the process have succeeded if it had been preceded by an adequate consultation on cardiac services across all age groups? Because of the other mistakes made in this exercise, one cannot be sure. But, for certain, it damaged the credibility of the consultation. That is because one of those mistakes was to refuse to heed consultees who raised the lack of co-ordination with adult services as a legitimate matter to be considered. Instead, the NHS ploughed on ahead.
From all this, we can offer three clear conclusions • Clarity of scope is critical. Precisely defining those aspects where the consultor is open to influence is essential. Vagueness just increases the risk of a pre-determination ruling at judicial review • Before determining that scope, consultors should extensively test it with key stakeholders. If too many target audiences feel that relevant issues are unfairly excluded, no amount of best practice dialogue methods will convince them • If a consultation clearly develops into a major disagreement about the scope, it is wise to re-consider; maybe the Safe and Sustainable project should have done so.
Trigger Points
Are you paying sufficient attention to the Scoping of proposed consultations?
To see the Independent Reconfiguration Panel’s Report on Safe & Sustainable Communities click here.
The Institute has published a News Brief as a commentary on the IRP Report and focused on the consultation/engagement aspects. Already sent to all Members, and now available to non-members on request.
Issues in this Topic are covered in the Institute Masterclass: Managing significant change in Health & Social Care.
If you found this of interest, you may also like to read Topic 233: Questioning the Expert
This is the 239th Tuesday Topic; a full list of subjects covered is available for Institute members and is a valuable resource covering so many aspects of consultation and engagement