Winning hearts and minds

Health and council leaders need to work harder to get the public involved, writes Richard Vize

The NHS has always struggled to find the right relationship with patients and the public. Clinicians and managers know that listening to local communities and service users helps them to understand what matters and identify ways the system can be improved, but virtually all parts of the health service find it difficult to do.

The need to get this relationship right is brought into sharp focus by the move to devolve control of health services to local areas. While Greater Manchester and other places are gaining additional powers over health through devolution deals signed between ministers and groups of councils, every part of the country has a greater decision-making role in the future of their local services through the sustainability and transformation plan (STP) process.

Under this programme, the country has been divided up into 44 areas, each of which has delivered a proposal to NHS England on how it will make the local health economy clinically and financially sustainable. This means sorting out hospital deficits, and moving care from hospitals to the community to keep people with longterm conditions living independently for longer at lower cost to the state. Crucially, councils are often playing a central role in devising STP plans. Consultations on them has barely begun; excessive secrecy in the early stages predictably triggered a wave of “secret plans for NHS cuts” headlines, maximising the chances of public opposition.

‘Devo deals’ and the STP process are driven both by a recognition of the harm caused by years of excessive central control of the NHS, fettering the ability of managers, local politicians and the public to shape local health priorities, as well as the growing respect for local government as effective leaders of communities and managers of services. For the first time, place and community are central to health service planning.

But the Fabian Society polling and focus groups reveal how little the public understands the term ‘devolution’. This May’s elections for ‘metro mayors’ in places such as Greater Manchester, Liverpool City Region and West Midlands may encourage wider understanding, but with a mixture of mayors, combined authorities, councils and health service structures involved, it is hardly surprising that few people have a clear idea what it all means.

The research also highlights ambivalence over who should exercise local control, and a conservative view of how much latitude they should have to make changes.

Inevitably the ‘postcode lottery’ comes into play, with a strong desire for uniformity rather than responding to the varied needs of different communities. With a handful of clinical commissioning groups now pushing the legal boundaries of their powers to restrict access to some services, simply to save money, pressures around this issue will only grow.

The overwhelming support in the polling for clinicians – as opposed to managers – making decisions about local health services exposes one of the major weaknesses in attempts to involve the public, namely the lack of trust in those running the services.

This is often exacerbated by the use of opaque, patronising language in consultation documents which fail to spell out exactly what services are going to be delivered and how. Trust is further undermined by a lack of openness around issues such as the need to save money.

Michael Gove will be disappointed that support for ‘experts’ remains, with 38 per cent backing the statement that “local residents don’t understand enough to help make decisions about healthcare. This should be left to experts”. Around 34 per cent wanted local residents to have more say. In the focus groups support for experts was stronger still.

The government’s decision not to give metro mayors powers over health is supported by the research; all the focus groups regarded mayors as unfit to oversee healthcare. Support for giving power to councillors was weak. Coupled with the support for experts, these results indicate that the public prefers health decisions to be guided by evidence rather than politics.

There are tough messages in the research for health and local government leaders about how they involve the public in healthcare.

They need to work far harder at explaining what devolution means for local people and how they can get involved in consultations and decision-making.

Careful thought is required on what exactly the public are consulted on and how it is done. People need to be involved in discussions that matter to them, such as services they are likely to use, rather than broad, vague policy questions.

Involvement needs to be early, open and influential. Almost invariably, consultations over changes to health services come at the end of the process, when the public is confronted with a proposal which is unlikely to be changed. Public involvement from the beginning allows valuable insights to shape the ideas at the heart of the project.

Early involvement is also far more likely to engender trust in what service leaders are trying to achieve; as endless attempts at changing hospital services have proved, springing a plan on people – particularly one which looks like a cut – risks being swiftly mired in stubborn opposition.

However, the research also reveals the limits of public involvement in health devolution. People insist on transparency and openness and an opportunity to have their say, but only a minority will ever get involved.

Image: Stacey McNaught