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Published 5 December 2014
Early engagement with patients, carers or service users when redesigning services is seen as essential. But this process can be time-consuming and expensive.
As services are integrated, patients and carers need to be kept informed of simple issues like changes to organisation logos on signs or headed notepaper, or front desk staff wearing different uniforms, as well as larger scale structural changes to the way services are delivered.
Patient or carer stories about past experiences of poor or inefficient care are one of the key tools in driving the agenda for change. Some organisations invite patients to share stories of poor care and ideas for improvement as a useful way of bringing staff on board.
Staff need to know that changes are ultimately patient-led rather than “a management-led cost-cutting measure”, said Julian Emms, the Chief Executive of Berkshire Healthcare NHS Foundation Trust.
“When we were planning to integrate child therapy services, we invited parents and children to come and share little vignettes about what it was like for them. They said that, clinically, care was very good, but that the service was 'lumpy and bumpy’ across different agencies, where you had to tell your story all over again.”
Nick Temple, Social Enterprise UK’s Director of Business and Enterprise, said that most social enterprises delivering health services have representation of staff and/or the local community on their board or in their governance structures, which provides a direct way for stakeholders to input their views.
More broadly it is “hugely important” to involve stakeholders at the preprocurement stage, he added. “Once the tenders are written, it becomes difficult for engagement to be meaningful.”
Engagement on a wider scale is also seen as an opportunity to build up relationships across and within different systems. “We co-produce things with our lay partners as they do a better job of breaking down barriers than professionals. They say why they want changes and ask why we can’t do things in a different way,” said Thirza Sawtell, Director of Strategy & Transformation, NHS North West London Collaboration of CCGs.
Dr Muhammed Ali, Clinical Director of the North West London Integrated Care Pilot, said that his area has the advantage of having worked collectively for a number of years.
“The last 11 months since becoming an ‘Integration Pioneer’ have been more intensive. Discussions to date have been helpful and overall amicable, but we have yet to crunch down on the money and governance issue as it gets to the operational go-live, the point of no return.”
Paul Haigh, Chief Officer at City and Hackney CCG, said that, while there may be agreement with the principles behind changes, “when you get down to the nitty-gritty stuff, where people feel they may be giving up power and responsibility. People will sign up to the idea of wrapping services around patients and blurring the boundaries of organisations, but it gets difficult when money is moved around and organisations start getting a bit cautious that they will lose out. So it is important to develop trust and mature relationships.”
Some respondents worried that the proliferation of NHS organisations and other stakeholders makes the engagement process difficult and costly. James Reilly, the Chief Executive of Central London Community Healthcare NHS Trust spoke of a recent lengthy public service reconfiguration, which reports suggested had cost in the region of £17 million.
“There were 11 providers and 8 CCGs involved: patient consultation and engagement can be expensive and time-consuming.”
Often there is a legal obligation to consult with stakeholders, particularly where there is going to be a change in the way services are delivered, states Anne Crofts.
“A failure to consult properly can lead to a challenge by way of Judicial Review. Challenges based on consultation issues have proved to be fertile ground for those who have substantive objections to proposed changes, and they create very significant delays and relationship issues. But consultation shouldn’t be viewed as just a defensive measure or process to be got through; as our respondents have indicated, it is an immensely powerful tool.”
Ros Ashcroft of DAC Beachcroft said that, in order to effectively mitigate legal risks through consultation and engagement, “organisations need to think carefully about the questions they ask – it’s less about asking people whether they agree with the proposals and more about seeking information on how changes would affect different service users and other stakeholders”.
This can help prevent consultation ramping up the antagonism of the public, she argued, giving valuable insights on practical issues, as well as making decisions more legally robust. But Ros also warned that, to gain these positive effects, consultations need to be truly open about why changes are being proposed, how they would work and what this might mean for the public.
“This can be a real challenge when the processes for both agreeing proposals and implementing changes are going to be complex.”
The answer will often be to avoid using the traditional model of a single large public consultation at a fairly advanced stage in the process of change. Instead, it may be better to carry out a range of consultation and engagement activities at different stages of the reconfiguration process.
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