Image: Flickr/David Lewis
Throughout London health services are under pressure and facing attempts to cut capacity and reduce accessibility to services on the back of dubious claims of quality improvement.
The People’s Inquiry into London health services held a series of meetings over the autumn, culminating in a lively meeting in Lewisham hospital on 6 December. The Chair of the Inquiry, Roy Lilley, posed the question at the end: why is it so difficult to engage with local people over questions of reconfiguring health services?
If ever there was a case of the people vs the state it was shown in all its glory in Lewisham, with the people successfully defending local services in Lewisham hospital – at least for now. But the Secretary of State is desperately trying to change the law to enable administrators to short circuit the normal public consultation processes so as to ignore the views of the public on these key public concerns. Nervous MPs will be debating that one soon.
Campaigners will again fight their corner for the people with the Secretary of State representing the forces of dictat from the centre. But how did it come to this - and is there a better way?
Should we reduce public involvement?
The theory of public participation in decision-making suggests major benefits:
- Enhanced information and ideas on public issues;
- Public support for planning decisions;
- Avoidance of protracted conflicts and costly delays;
- Reservoir of good will which can carry over to future decisions; and,
- Spirit of cooperation and trust between the agency and the public.
Public involvement and engagement remain required by law, with duties to consult with the public on significant NHS changes. But NHS managers have never embraced public consultation with enthusiasm. More often than not changes are contested and end up being referred to the Independent Reconfiguration Panel which suggests significant changes and tends to involve years of delay. This was the case before financial pressures started to bite. With the prospect of many more cost cutting reconfigurations in the pipeline, matters can only get worse.
Should we accept what the government and NHS leaders are pursuing – the dismissal of the role of the public in determining the future shape of services? Or should we continue to develop the involvement of patient and the public at large in how services are delivered?
Reconfigurations are expensive. They tend to be argued for on the clinical case that further investment in community care will reduce the demand for emergency services.
The risks and inconvenience to hundreds of thousands of people asked to travel further for emergency acute, obstetrics and children’s services are outweighed by the marginal quality improvements for some who may need services not ordinarily available in existing A&E departments.
Guidance on NHS consultations supposes it is possible to present business cases to the public that make clear a compelling case for change. But that is rarely the case. As we heard at the Lewisham meeting, facts and evidence are often distorted for what can only be political purposes, even when clinicians are involved.
The public is right to interpret proposals to rationalise services as crude cost-cutting measures designed to reduce access to vital local services.
Are Citizens Juries the answer?
If you believe in bottom-up solutions, either as a democrat or a free-marketer, you may be tempted by the promises of citizen participation in decision-making. Citizens juries - suggested by Roy Lilley last month - are just one of many forms of this.
But the theory of citizen participation is neither without controversy nor new. As this diagram from 1969 shows, there is a spectrum of citizen participation: citizens juries sit in the partnership box, one step beyond tokenism.
Public participation is one means of decreasing tension and conflict over public policy decisions which can have tangible benefits. However, the expectations of planners and the public must be roughly equivalent for the process to be effective.
Here is the nub of the problem. Planners are not confident in their arguments and are not willing to concede power over decision-making.
They assume that turkeys will not vote for Christmas and that active citizens worth their salt will not collude in agreeing to prune and centralise NHS services. In fact it may add to the difficulties in gaining consent.
As for citizens juries, there are limitations:
- The issue may be broad ranging and complex, not easily pinned
down in a simple issue to be resolved in isolation. For example is a quality
issue not merely a resources issue?
- A jury is normally formed to determine guilt or innocence and is perhaps not best designed to manufacture compromises in implementation of complex goals.
- The framing of the issues can be pre-emptive. Should debates on the centralisation of services, assume limits to staffing are fixed?
- Who chooses the jury and do they represent interests? In practice strong opinion shifts are observed in juries implying a high level of manipulation that would not be so easy with a representative structure.
- Selecting appropriate data and information is a problem not easily free of accusations of bias.
- A citizens jury is unlikely to be devolved real power, leading to accusations of it being a sham listening exercise or a costly PR exercise little better than other forms of token public involvement.
Who knows best?
The NHS is not a bottom-up organisation exploring how best to meet complex objectives. It is a top-down, managerially-led organisation trained to mimic the undemocratic ways of the private sector corporation. It is staffed by and governed by people trained to believe in expertise and technology, and prone to similar value judgements.
If the NHS were to use juries it would not be because its leaders thought it would generate better solutions but because they believed that juries would better deliver the solutions required by the NHS leaders.
Of course the NHS will deny the charge. It employs sophisticated communications directors and teams of consultants who believe in the theories of the public relations industry and behavioural sciences: of hidden persuaders, subtle nudges and manufactured consent. They have read their Gramsci and other theorists. They know how to frame a discussion and to create a narrative. They may even be into cutting edge thinking promoting faith-based solutions designed to promote “ethical” outcomes.
The trouble is that all these theories presume that those in power know best. But history suggests that decisions are usually scarcely concealed expressions of real vested interests with a grip on the levers of power.
So do citizens Juries provide the answer? They might if the question is how the NHS can win credibility for its dubious policy prescriptions; perhaps then citizens juries might help swing it.
But in circumstances of highly charged and controversial disputes on the configuration of services citizens juries are unlikely to produce a more acceptable decision for all parties or to leave all parties satisfied in the process. Instead they may serve to be another costly delaying tactic viewed from one perspective or a more subtle form of attempted manufacture of consent doomed to do little more than add fuel to the opposition pyre.
Is there another way?
There is no need for novel forms of public engagement. Neither is there a need for innovations in the process for taking controversial public decisions. What is required is more honesty and competence in definining the objectives, the costs and benefits of options on offer, and how they will work in practice. Reports into contested closures by the National Clinical Assessment Team reports and Independent Reconfiguration Panel reports have found there are usually less risky and cheaper options available to meet objectives.
Instead we have proposals that are rushed, driven by the need for management to present a way out of current financial difficulties. This is a premature basis to commit very large resources to a change process and reconfigurations affecting thousands of staff, hundreds of thousands of patients and hundreds of millions of pounds of investments.
And we have proposals that are scripted, standard solutions to perceived problems. It is no coincidence that so many proposals for change are so similar despite important differences arising in different localities for which other solutions would be more appropriate. In South London if the excess cost of PFI-funded hospitals had been funded earlier there would have been no need for services at Queen Mary’s, Sidcup to have been closed.
Organisations in difficulties need to work with local stakeholders and more flexible strategic bodies to better identify options and proposals for change. This is why due process has been created, consultation prescribed, time injected into the change process and leaders with judgement appointed.
The final words should go to Lawrence Freedman, the author of ‘Strategy’, in describing “the battle of narratives” which often takes place over contentious issues. What matters is not the inherent quality of the arguments but the resources behind them (p618).
"In terms of everyday human interaction, persuasion through story telling can be an important skill, especially when engaging those with similar backgrounds or interests. When engaging those who might be sceptical or suspicious, with separate frames of reference, they may be of less value. Moreover narratives deliberately manufactured to have some desired effect risk appearing forced and contrived. They suffer from all the faults once associated with propaganda, which lost credibility precisely because of its blatant use to influence how others thought or behaved. The plot falls apart as soon as clarity is required, empirical tests or evidence called for, and when contradictory messages emerge."
Unless public involvement is sincere it risks looking like the sham it often is. The problem with a jury is that unless it is rigged, manipulated or ignored, it risks not delivering the required results.
There is a way forward but it is not captured in attempting to railroad half-baked plans past the public, whether by citizens juries or otherwise.
This article first appeared on NHSManagers.net.