The NHS in England has published its ‘Next Steps’ document, taking stock of progress against the Five Year Forward View (FYFV) and charting the way forward. It is an intimidating paper – full of detail and with enough acronyms for a dozen alphabets. For all that, it is also highly revealing and is worth serious study for anyone who needs a better understanding of what’s happening than the ritual simplicities that the news media provide.

Our view is that the fundamental analysis of the challenges, and the overall approach as set out in 2014 remains largely unchanged. But the NHS has learnt several highly significant things:

• The demographics of an ageing population are changing even more aggressively than anyone thought, and consequent patterns and levels of NHS usage has risen more rapidly adding to financial pressures.
• The reorganisation of 2011/12 has proved even more disastrous than they thought –particularly for forward planning and led to STPs as the best available but non-statutory workaround to create half-decent plans.
• They made some mistakes in setting up STPs and now propose to drop the word ‘footprint’, tweak them a little and make key appointments and governance more transparent. They failed to consult on the draft plans, but realise the need for better engagement as and when they are implemented.
• Working with electorally-accountable local authorities is also harder than anyone thought, but some of this is due to the immense pressure on Councils to reduce their budgets.

Despite an overwhelming number of worthy initiatives to improve patient care and address health inequalities, it is clear that the NHS sees three priorities

• Improving the performance of Accident & Emergency – as part of a re-vamped Emergency care offering
• Strengthening access to high quality GP services
• Improvements to cancer and mental health services

Implications for consultation and engagement

One of the best aspects of the ‘Next Steps’ paper is a recognition that big-bang reconfigurations are only a relatively small part of the way forward. Yet they have dominated the debate in many parts of the country, virtually obliterating much else that is positive from the public consciousness. In some ways, it suggests a failure of public engagement strategies, so that the NHS receives press and media coverage mostly when patients and stakeholder groups campaign against service changes or ‘closures’, and only seldom to discuss innovative, or more beneficial developments.

Ideally, adoption of STP plans, and the creation of Sustainable & Transformation Partnerships should signal a better attempt to build and improve the effectiveness of on-going continuous engagement machinery. The larger scale of the 44 ‘areas’ lend themselves to this approach, especially as it means joint working with local authorities and countless other provider and stakeholder organisations. Pooling resources is rather more difficult than people think, but co-coordinating their efforts is vital. A single stakeholder database for each area might be a start!

There is huge, untapped potential in using better public involvement to secure support for important health education programmes. Initiatives on lifestyle-related illness prevention including obesity, diabetes, drug and alcohol misuse and so forth all lend themselves to local dialogue and co-production based approaches to solution development. Healthwatch and condition-specific pressure groups are particularly keen to work in this area; a modest investment in training and process development would yield immediate benefits. Consulting people about new ways to safeguard health and wellbeing would also help move away from the current view that If there’s a consultation, it must be bad news!

The fact remains that there will be resistance to service changes that appear to communities to be a reduction or withdrawal of service. When this happens, the NHS has no choice but to run the best-possible public consultation it can, with sensible alternative options that have emerged from better pre-consultation dialogue, and free from any evidence of pre-determination. That only happens if engagement is worked into the process much earlier, and if we discourage over-enthusiastic Managers and external consultants from arriving at a definitive view of ‘the answer to the question’ before consulting the wider community and seeking other informed opinions first.

Politicians have an important role in setting the climate for engagement. Many MPs who support service changes in the NHS in general, have been vocally critical of consultations affecting their own constituencies. Failure to observe best practice provides them with irresistible ammunition, and it must be a goal for STP areas, going forward, to ensure that they are not vulnerable to political or legal challenge – so that the debate can focus on the substance of the proposals – and not the process.

The same analysis applies to Health Overview & Scrutiny Committees. Unlike MPs they have the power to refer service changes to the Secretary of State, but we know little about the dynamic of these processes – except anecdotally. The NHS needs to get to grips with this interface as it is one of the major risks to successful implementation of some STP plans.

The King’s Fund Report on delivering STPs in February concludes that “a huge effort is now required to make up lost ground, engage in genuine consultation on the content of STPs, explain the case for change and the benefits that will be delivered”. Alongside that we should hear the Chair of LGA Community Wellbeing Board, Councillor Izzy Seccombe, commenting that “It is vital that (Councils) are involved and not just consulted afterwards on pre-determined solutions. Any failure to engage councillors could lead to vociferous opposition”.

The task for those committed to the engagement and consultation agenda is to address these challenges.

The Institute’s View

• The Next Steps document is really useful in painting a much wider picture of the changes being sought by the Managers of the NHS. But it is a massive and complex set of messages. Communications teams need skills and ingenuity to find ways of transmitting them to stakeholders and the general public, so as to secure a better-informed debate.

• If this works, there is a chance of developing an improved process of continuous engagement, but, unlike consultation – where there are strict rules and legal standards – engagement is a looser, less precise concept, so the Institute has worked with the NHS in Wales to develop a framework to evaluate and measure its effectiveness. It is now being implemented in two Health Boards. To find out more, contact Jan Warner or Karen Fourie on 01767 318350.

• Implementing STP-based service change options will involve a considerable number of consultations, and whilst most will be for the customary 12 weeks, there may be a case for shorter exercises in some cases. The Institute has worked with the NHS North East Commissioning Support Unit to develop a shorter-but-better process, which may be ready for use during the summer months. Contact the Institute for details.

• The use of an independent Quality Assurance to underwrite the credibility of public consultations, and to encourage best practice, is now well-established. The Institute has conducted a large number in the NHS and beyond and is happy to discuss its relevance to NHS Managers in specific areas.

Relevance

This Briefing is of relevance to Senior Managers in the NHS and local government who are involved in the STP process, Clinical Commissioning Groups, Foundation Trusts and other Health Providers. It also affects Council Leaders and Elected Members as well as members of Overview & Scrutiny Committees, Healthwatch and voluntary/community organisations with an interest in health and social care.

Further insights

• This Briefing was written by Rhion Jones LL.B, Programme Director of the Institute, assisted by active Institute Associates who are working with various STP plans.

• The Institute has recently worked on a methodology for options appraisal and scoring, and has developed a realistic role-playing exercise to help Managers become familiar with the issues involved in these aspects of preparing proposals for public consultation.

• It was also commissioned by NHS England to develop and deliver Workshops for Managers and others involved in STPs in the Midlands and East of England. These focused on applying Guidance and best practice and included a shortened version of the options appraisal role-playing exercise. To find out more, please contact the Institute office where colleagues can discuss in-house deliveries of similar Workshops to interested parties.

• Co-production is still under-developed in the NHS and experienced facilitators are available to help organisations move in this direction.

• The Institute runs public training courses on a wide range of consultation and engagement issues.