Service re-design ... through consultation - Whose input do we need if a financial squeeze requires a total re-think of public services?

So after the next General Election, will public expenditure be cut by 10%? Or less ... or more ... ? Of course it depends whom you ask?

10% says the Tories’ Andrew Lansley, whose sums assume that preserving the NHS budget means that everything else is cut more aggressively. Less says the Government which claims that ‘Red Book’ assumptions may be a little pessimistic, especially if there are (hush, don’t say it too loudly) a few green shoots around .... More, if we listen to Vince Cable .... Oh dear! So let’s turn to one major service area and look for the most authoritative figures we can find, free of party politics. Three cheers therefore for the NHS Confederation’s paper on Dealing with the downturn (see below) which should be mandatory reading for everyone in Health and Social care, and useful too for those working in a wide range of other service areas where the same principles will surely apply.

What this paper says is this. From 2011, the NHS will face a contraction of £8 - £10 billions in real terms, and that the only way to address this shortfall without recourse to proven disasters, like increased waiting lists and ill-considered reorganisations, will be through strong leadership and radical improvements in quality and efficiency. In a fascinating analysis called Learning from history, it produces a catalogue of bad ideas and initiatives over which extreme caution should be exercised! Most other public services could do with an equivalent list!

What is do-able is a range of radical service re-designs in what health professionals call ‘care pathways’. In a complex inter-dependent structure like the NHS, this is a formidable challenge – as is major change management in any large-scale business. In this context, it is clear that a critical success factor is the involvement of key stakeholders and, in this instance, we not only think of clinicians and other staff; we consider patients, carers and, of course, the general public. The Care Quality Commission has just reinforced this with its Involvement strategy, which includes commitments to use Panels, Surveys, traditional consultations and also to develop its Experts by Experience scheme. It also confirms its intention to work closely with Local Involvement Networks (LINks).

All public services need to establish a similar approach, though the details will obviously vary. But almost everywhere the way things have been done in the past 20 years will have to change, and re-designing services will become absolutely essential. Business process re-engineering (BPR), your time has come!

Involving stakeholders and others in such tasks requires different skills from traditional consultation. There have to be some shared (though not identical!) goals; there needs to be a degree of knowledge – sometimes technical, and an awareness of new options. The ability to discern the difference between negativity from wishing to keep the status quo and genuine doubts about alternative scenarios becomes an important attribute for project managers. Front-line experience becomes essential. But, on occasions, the service re-design may need to be so radical as to remove the service altogether. There is an ominous new term we will hear only too often – service decommissioning. It is already in the NHS Confederation paper, and the world of local government has also begun to use it. It’s not the same as ‘cuts’ but many will fail to see the distinction.

Here, also there is a strong case for involving stakeholders. In fact, it is stronger, and some of these discussions will be difficult. Surely best practice requires that, before services are withdrawn, those who are affected are consulted? If we use such techniques as Participatory Budgeting to involve the community in decisions to spend money, should we not use the same methods to decide how to save money, and how to stop spending? A sort of PB in reverse, perhaps?

The trick is to start soon. The NHS and other services are not facing drastic reductions immediately. But the lead-time for effective re-design is lengthy, and there will be awkward decisions as to whom exactly to involve. This is where representative bodies with legitimacy have an important role to play. In the Health Service, this is the big opportunity for LINks to make their mark – though not everyone sees it in this way. Co-design becomes almost impossible in a confrontational or adversarial environment, and we hope that it is the prize of more cost-effective outcomes that will most encourage co-operation rather than the sheer severity of the financial squeeze. Squeeze there will be – but for consultation and public engagement, it is the time to add genuine value to decision-making.

Trigger points

• Given the importance of the NHS Confederation analysis, we will amend the agenda for the Seminar on Developing LINks as effective champions of dialogue. We will now provide time to consider the Dealing with the downturn paper and its implications for LINks.
• The NHS Confederation paper is available.
• The Care Quality Commission Involvement Statement is called Voices into Action.

This is the 138th 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