Daniel Reynolds

Even if there are major benefits to be had for patients, the prospect of local NHS mergers, reorganisations or closures always results in high profile protests. People will go to great lengths to preserve the status quo – no matter how well articulated the case for change.

NHS trusts and the wider health and care system stand on the verge of some of the most significant conversations they will have with local communities as 44 sustainability and transformation plans (STPs) are being developed across the country. They hold the key to the pattern of care delivery over the next decade. There will inevitably be controversy as much-cherished local services, including A&E departments and maternity units, may face being downgraded or even closed.

So far, the STPs have largely been off the public’s radar. But they are about to hit our consciousness in ways that will have profound consequences for their success or failure. While it is unfair to say that STPs have been shrouded in secrecy, an unhelpful narrative of a “stealth” cuts agenda is already being fuelled by campaign groups, Opposition politicians and sections of the media who are thirsty for emerging insights from the plans.

Playing catch-up

Before the plans have even been published there is a palpable sense the NHS will need to recover lost ground in the battle for local hearts and minds when it comes to convincing a sceptical public that change is needed. How effectively patients, local communities and other stakeholders are engaged in this process is one of the risks that have been identified by NHS trusts and system leaders.

Planning for this task is complicated by the fact STPs, while being a positive mechanism for planning beyond individual institutions, are not formal organisations but geographical footprints with no legal basis. Responsibility for engagement and statutory consultation on proposed changes rests with the boards of NHS trusts, local commissioners and councils.

New guidance from NHS England attempts to clarify this by setting out what is expected from each STP “footprint”. Most areas will need to take a version of their plan to their respective organisation’s public board meeting for discussion between late October and the end of the year, and NHS trusts are being advised to devote a public board meeting to discussing the proposals.

While NHS trusts, CCGs and councils have separate duties to consult, NHS England is encouraging joint public involvement exercises to reduce duplication, save resources and maximise engagement across communities. Their advice is for STPs to clarify organisational roles and responsibilities and to avoid reinventing the wheel – for example, by tapping into existing networks and working with councilors who have strong community links.

Ultimately, NHS trusts will need to take a judgment about how and when to engage their communities in any proposed changes. The risk of legal challenges and judicial reviews will increase if this engagement is not carried out sufficiently early on in the process.

There is a palpable sense the NHS will need to recover lost ground in the battle for local hearts and minds when it comes to convincing a sceptical public that change is needed

A range of partners will need to be involved in this, including the public, clinicians, and organisations across primary care, social care and local government. This should start as soon as possible and all stages of activity should be documented. In many STPs this appears to have been patchy and sporadic at best so far.

Moving beyond standard approaches to consultation

The chances of successful engagement will be enhanced if trusts and their STPs go beyond standard approaches to consultation. These are often divisive, come too late in the process and rarely deliver the kind of mandate that is needed for transformational change. Consultation is a legal requirement but it should follow public engagement, which needs to start early and run throughout the process.

The rapid timescales of the STP process make this tough but trusts and their STPs should attempt to foster ‘genuine co-production’ to ensure local communities are engaged in decisions. As the Institute for Government’s work on Smarter Engagement indicates, waiting for formal consultation to begin when plans have more or less been developed risks trusts and STP leaders being forced into what it has coined a “decide and defend” strategy.

Transparency is key

This situation has perhaps not been helped by inconsistencies in how emerging plans are being revealed to  communities. Although not universal, some trusts have reported they have been discouraged from sharing emerging plans until they are fully developed and centrally assured.

In some areas, this has in part served to limit the degree of clinical and non-executive director input. Only around half a dozen STPs have published their draft plans. On one level the desire to work up plans more fully before sharing is understandable, but it risks feeding the narrative of a “stealth cuts agenda”.

Changes to local services will always attract controversy and public concern, no matter how well articulated the case for change

It’s important that STPs are as open as possible, although this presents a genuine dilemma for local leaders. It would be a mistake to rush into early engagement on plans that may be undeliverable and which will inevitably change over the next few months. But it’s important local leaders at least make the case for change and outline the process that will follow.

This doesn’t mean rushing to consultation as it would be wise to develop the plans iteratively before any formal process begins. But it does mean delivering a suitable period of early engagement rather than continuing to develop plans in private and waiting for the optimum moment to go public – the latter rarely exists. This should pay dividends down the line when proposals go out to consultation.

All of this is not to underestimate the scale and complexity of the challenge that trusts and STPs face. Changes to local services will always attract controversy and public concern, no matter how well articulated the case. That is why effective approaches to public engagement based on transparency, openness and a collective discussion on the trade-offs stand a much better chance of securing less divisive outcomes than traditional, more limited approaches to consultation.

This was published by HSJ on 10 October 2016