The cry of frustration uttered by so many stakeholders…

This is scarcely a sentiment confined to the National Health Service, but it was NHS England Chief Executive, Simon Stevens who raised the issue in his frank admission last week. Hospital beds had become ‘overly pressurised’ he said, reflecting on the 10% reduction over the last decade. He went on to say that “in many areas, the NHS is going to need more bed capacity to deal with demand.”  The new approach represented “quite a significant gear-shift”, he said. Others just called it a U-turn.

Stevens is a canny political operator, and it will not have escaped his attention that there are politicians out there applying for the job of PM. But he also has a track record of disarming candour, more ready than other bureaucrats to admit to mistakes and willing to trim a policy and respond to arguments. Reacting to the news, Chris Moulton, vice-president of the Royal College of Emergency Medicine, said he was ‘delighted’ and that the NHS has reduced beds “acting on poor advice from experts”.

Regardless of which experts are right, one can hear thousands of consultees shouting “I told you so” as they recall unsuccessful attempts to dissuade local NHS Trusts and CCGs from approving reorganisations that involved controversial bed closures. How many of them have been incensed to see the very deterioration in services that they predicted? Are they not tearing their hair out wondering what is it that they could see in their local NHS facilities that Government Ministers, Simon Stevens and all the other senior decision-makers could not? Telltale signs emerged two years ago when Stevens introduced an additional test by which re-configuration proposals were to be assessed. It was called the ‘bed closure test’ and what was a green light for closures became a flashing amber one! The gear-shift actually started a while ago.

As always, the truth is more complicated. There are, without doubt, cases where bed reductions have been well planned and have enabled a re-prioritisation in favour of other services. But others have run into difficulties. A favourite narrative is that beds have been occupied by patients who might be better cared for ‘in the community’ and therefore the bed reduction may be contingent upon those community services being funded and delivered. Note that Stevens shrewdly got approval for the NHS long-term plan on condition that the social care funding gap would be addressed.  Under these circumstances, consultees who feel their warnings went unheeded might argue that the consultation failed to do its job. Have their efforts been in vain? What can they salvage from their experience?

Here are three suggestions. And they are not confined to the Health Service…

1. Consultation may sometimes be a one-off, but public involvement is a continuous process. Consultees who turn up to comment upon a particular set of proposals, welcome though they are, will never have the same influence as they would if they participated over the longer-term. After all, it is easier to say No to specific proposals than it is to help solve intractable problems. Machinery for continuous dialogue is therefore vital and why it is worrying to see the Welsh Government axe Community Health Councils, without sufficient confidence that the replacement body will be better. If local representative groups and individuals are convinced that consultation proposals are ill-considered or their impacts underestimated, their role does not end when the consultation closes.“I told you so … once in a consultation” is not as effective as “I keep telling you …”
2. Top-down narratives will not always fit local circumstances, and it is often right to challenge them. Policy reversals like the Stevens U-turn are not rare. Governments as well as local authorities and innumerable public bodies are prone to persist with accepted orthodoxies long after their limitations have been proven. The way policy-making works is that everyone is told to tow the party line until there is a new one. In the NHS, the bed closure narrative has been a standard text in consultations for several years. Consultees can plainly see the ‘cut and paste’  jobs that find their way into consultation documents, and should probably be more robust in questioning whether local Managers have the evidence and the numbers to support what is probably a national rather than a local direction of travel. In particular, consultees should scrutinise Impact Assessments. A bottom-up approach, including effective co-production processes has so many advantages.
3. Monitor the implementation phase.  NHS England’s mind-change has probably occurred because of the bitter experiences of those who pushed through ambitious transformation projects. One does not need to be an avid watcher of fly-on-the-wall documentaries about our Ambulance service or pour over NHS performance statistics to know that whatever slack there was in the hospital system is long gone in many towns and cities. Unfortunately well-meaning Managers facing a tough balancing act, do not, themselves know whether the changes they make will prove effective or not. What they need during the implementation phase are constructive stakeholders who will count to ten before spitting out the ‘I told you so’  line and, instead, help find solutions and mitigations. Must be tough, but swallow hard – it’s for the best!

Does this amount to asking consultees to be super-human, to bottle their frustrations and turn the other cheek? After all, many Senior Managers in public services are unnecessarily and gratuitously rude about their efforts. Yet constructive dialogue relies upon the development and maintenance of good personal and professional relationships. What Simons Stevens illustrates is that eventually, for whatever reason, key stakeholders like specialists in Emergency Medicine had probably been right all along. They will be wise not just to say, “I told you so”, and instead work with Stevens to improve the service. He should appreciate it!

Yet another strong case for co-production!

TRIGGER POINTS

1. In your own organisation, have there been consultations reflecting top-down rather than bottom-up approach?
2. Have you adequate machinery for continuous dialogue?
3. Have any of your consultees used the phrase “I told you so …” If so, did they have a point?
4. Are the state of your stakeholder relationships conducive to a positive dialogue?
5. The Politics of Consultation recommends a set of three Consultee Rights as well as Three Duties of Consultors.
6. The preparation of consultation narratives is covered in the Institute Training course Conducting a Public Consultation

This is the 349^th 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.