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Lessons from the Safe & Sustainable saga

It is not very often that a Government Minister has to come to Parliament to explain that a high-profile consultation “did not have the confidence of the public”. Yet after years of indecision, £6m of taxpayers’ money, two High Court cases and a terrific media campaign by parents of very sick children, we still appear to be far away from rationalising the locations of children’s cardiac surgery in the NHS in England.

The latest twist in this long-running saga was the Report of the Independent Reconfiguration Panel (IRP), set up by the Department of Health some years ago as a kind of final arbiter on contentious proposals for change in Britain’s much loved Health Service. In a 142 page Report published on 12 June(1), it comprehensively demolishes the proposals that had been the subject of such acrimonious debate; in the words of the Rt Hon Jeremy Hunt, the Secretary of State, “the outcome of the Safe & Sustainable review was based on a flawed analysis of the impact of incomplete proposals.”

This may well send a shiver down the spines of Health planners – or indeed anyone seeking to implement drastic change to our cherished public services. On the surface, it looks as if politics has triumphed over pragmatism, with respected figures like Sir Ian Kennedy strongly critical of Governments for continuing to defer difficult decisions.

This Brief tries to disentangle some of the issues that have become blurred and seeks to identify lessons to be learnt for all who need to organise public consultation and engagement exercises.

In brief, the Safe & Sustainable review sought to reduce the number of hospitals performing children’s cardiac surgery and allied activities. The process involved a major consultation – which was challenged in the Court by the Royal Brompton Hospital (which initially won, but the decision was reversed on appeal) and also by campaigners for the Leeds Infirmary who won their case.

Following a decision one year ago to close Leeds, Leicester and the Royal Brompton, Overview & Scrutiny Committees exercised their right to refer the decisions to the Government – and the IRP Report is the outcome of that process.

The key fact for readers of this Brief is that, although the Panel considered and comments on failures in engagement and consultation, the principal focus of the Report is on the substantive proposals and the wide range of criticisms made of the NHS’ approach, analysis and assessment of impacts. Nevertheless, there were trenchant criticisms of the entire process, and here are some of them:

  • Over-complex and unfriendly 230 page consultation document
  • Only an online questionnaire was available in early stages of the consultation
  • Insufficient attention given to BME and other minority groups
  • “the methods used to support engagement were not based on best practice …”
  • Restrictions on the number of people able to attend consultation events
  • Parents felt “…the NHS had portrayed them as selfish, emotional parents unable or unwilling to see the bigger picture.”
  • Unease at the role played by a single representative body -The Children’s Heart Foundation (CHF) and the influence it had on the weighing given to the access criterion
  • Media statements issued by the NHS and CHF were ‘combative in style, serving to polarise the debate and unnecessarily antagonise those raising their concerns.’
  • Insufficient weight given to a petition with 600,000 signatures
  • Bias in the Steering Group: “ …membership of the Steering Group, although ostensibly based on representatives from professional associations, included people with a connection to all of the surgical centres included in the review with the exception of the three that were subsequently selected for de-designation at the end of the process.”
  • The final decision meeting considered additional options that had not been subject to consultation and engagement
  • The NHS had failed to respond to reasonable requests for information and “displayed contempt towards legitimate public scrutiny …”

Now many of these are frequently heard and reflect common frustrations with consultations of all kinds; IPSOS-Mori, for example, responded to the point about petitions being recorded adequately in the data analysis.

The truth is that the consultation exposed weaknesses in the proposals being placed in front of the public. Serious-minded consultees, trying to argue their case claim they were met with a barrage of public relations spin.

“The Panel found that there had been a strong emphasis on a communications strategy and the key messages to be transmitted but inadequate attention to developing a genuine engagement strategy from pre-consultation to decision, underpinned by a rigorous stakeholder analysis”  (p.140)

On the proposals themselves, the Report is scathing on poor, inadequate or incomplete evidence. It said that the NHS “used information selectively” and the process lacked transparency. The public were left guessing as to what exactly would be the ‘patient pathways’ that would replace current services. There was no evidence they were sustainable in the longer-term. No-one had tested the proposal’s financial viability, nor their affordability. Maybe the greatest flaw was to try to reorganise children’s cardiac surgery in isolation from adult cardiac services, and without acknowledging the knock-on effects of one on another.  In short, the scope of the exercise was an error and the single-minded pursuit of fewer surgical centres led to a bureaucratic disaster.

“Much of the opposition to, and flaws in, the proposals originate in the lack of engagement of a wide range of stakeholders in the co-production of network models of care at the pre-consultation stage”

One could scarcely wish for a more clear-cut demonstration of the inter-relationship between the substance of proposals and the processes through which they are prepared and consulted upon.

The Institute View

  • This is highly significant for NHS re-configurations throughout the UK but has lessons also for other public bodies planning controversial changes to services
  • It shows how critical it is to agree a viable and defensible scope for the consultation
  • Proposals must be evidence-based  and the evidence must be presented fairly and transparently
  • Beware confusing ‘communications’ with ‘engagement’. They are different  and merged functions need to be aware of the risks
  • Project governance must avoid any bias, inadvertent or not
  • Avoid over-reliance on a prominent stakeholder claiming to be representative
  • Lessons from this Report are being incorporated into the Institute Masterclass: Managing significant change in Health & Social Care, which already considers the role and impact of the Independent Reconfiguration Panel.
  • This Briefing was written by Rhion Jones, Programme Director of the Institute, and who may be available for discussion. Telephone the Institute Centre of Excellence in Biggleswade on 01767 318350Further insights
  • Many of the failures evident in the Safe & Sustainable Review would have been detected had the exercise been subject to the Institute’s Compliance Assessments process for contentious consultations. Several other high-profile NHS consultations either have or are undergoing such Assessments and hope to be awarded the Institute’s Certificate of Best Practice.

Briefing Notes are published by the Institute in good faith as a member benefit, but the information provided cannot be relied upon as constituting advice giving rise to any legal or other liability whether express or implied.

(1) “Advice on Safe & Sustainable Proposals for Children’s Congenital Heart Services”,  available on www.irpanel.org.uk

This is the 10th Briefing Note; a full list of subjects covered is available for Institute members and is a valuable resource covering so many aspects of consultation and engagement

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