185.The NHS’s history has been one of repeated reorganisations. In contrast to previous reforms, we heard that the NHS Five Year Forward process, rather than spending time redrawing the map of the NHS, is supposed to focus on improving the relationships and behaviours between local services. This is a pragmatic approach, particularly given there is little appetite within the service for another set of legislative reforms in the wake of the Health and Social Care Act 2012.
186.National bodies have attempted to harness local support and energy across the health and care community, at a time of rising pressures and limited resources. However, a key message from our inquiry is that there needs to be a clearer narrative to explain the direction of travel: what are these reforms trying to achieve; what does the end state look like; what are the risks and what the benefits for patients and taxpayers.
187.There has been great variation in the extent to which local communities and their representatives have been informed and involved. Nigel Edwards, Chief Executive of the Nuffield Trust, explained:
perhaps the biggest weakness, not just with the STP process but arguably with the “Five Year Forward View”, is the lack of a very strong story about what we are trying to achieve, where we think we are going, what the advantages of that are and what the risks might be. That has been largely absent.
188.Based on the evidence we have heard, a compelling narrative should:
a)articulate what high-quality integrated care looks like, its benefits and the litmus test for success from the patient perspective. A compelling narrative would describe integrated care from a patient perspective. The NHS Five Year Forward View was a vision for how the system needed to change. It articulated the benefits of change primarily from a system perspective. However, when it comes to communicating the case for change locally, describing the benefits for the system as a whole is not the best starting point.
The public want to know how proposed changes will improve care for them, their families and their local communities. Despite this, many of the original sustainability and transformation plans used the Forward View as the starting point for the local service changes proposed within these documents. London Southbank University’s analysis of the South Yorkshire and Bassetlaw STP highlighted that it was one of the few plans that did not use the NHS Five Year Forward View as driver behind the plan.
b)focus on reform from the bottom up by supporting frontline staff and removing barriers to integrated care. There is widespread support for integrating care at patient and local level across the health and care community. The benefits of delivering holistic, joined up care for patients are recognised by staff. Dr Nagpaul from the British Medical Association made clear that “the workforce does not go into a hospital or a GP’s surgery thinking “STP.” People look at their lives in terms of looking after patients within the setting they are in.”
There is widespread support for changes that support health and social care staff to integrate care from the bottom up and to remove barriers to joined up working and information sharing. We heard that many frontline staff have spent large parts of their professional careers trying to integrate care for patients, often working around policies that construct rather than remove barriers to integrated care at local level.
c)provide clarity on what the shape of the health and care system will look like. One of the problems arising from the lack of a clear narrative, according to Dr Charlotte Augst from the Richmond Group, is that the “ ill-defined nature of the STP endeavour means that people can project on to it whatever anxieties or hopes they have about it.”
NHS providers, clinical commissioning groups and local government have called for greater clarity over the future shape of health and social care, particularly the role some of the current functions, such as commissioning, should play within a more collaborative, placed-based structure.
d)be based on a realistic, open and honest dialogue with the public. Nigel Edwards from the Nuffield Trust cautioned that it is important not to over-extrapolate the benefits of integrated care and the time and money required for transformation. Professor Katherine Checkland from Manchester University, who leads the evaluation of the new care models programme, told us “at the micro-level, as Nigel said, there is good evidence that integration is good for patients, but it is not at all clear that it will reduce overall activity or costs. There is a lot of fairly clear evidence that that is not the case.”
189.The vast majority of the British public continue to support the principles of a national health service that is tax-funded, comprehensive and free at the point of delivery. Most people agree that the NHS is crucial to British society and that everything must be done to maintain it. According to Ipsos MORI this has been a popular and stable belief for almost two decades. From 2000 to 2017 the percentage of people agreeing with this statement has ranged from a low of 73% to a high of 79%.
190.Compared to other countries, British people are more worried about the future of the health system. For example, 47% of British respondents to an Ipsos MORI survey expect the quality of care to get worse over the coming years - higher than all the other countries surveyed. The public increasingly recognise that the NHS is struggling with funding and workforce pressures.
191.Health reforms in western countries are often controversial. However, pressures on the health and social care system, and the public’s perception of these pressures and their causes, make the challenge of transforming care even more difficult.
192.Trust in Government, politicians and system leaders has long been low and despite doctors and nurses enjoying high levels of public trust compared to other professions, mistrust among the public plays into local changes to services. Ipsos MORI are regularly commissioned by NHS organisations to support consultations involving local changes to healthcare services. Kate Duxbury from Ipsos MORI told us that the company is finding higher levels of mistrust among the public in this work.
193.The campaign groups we heard from during this inquiry described how trust in national leaders, including NHS leaders, has eroded following a series of reforms to extend the role of choice and competition within the NHS.
194.Public distrust is also fuelled by the way national and local bodies communicate. The use of jargon heightens suspicions among the public, thereby making the challenge of implementing changes even more difficult.
195.Communicating the case for change is not a simple task. Kate Duxbury from Ipsos MORI described how within an STP there are so many “different issues that matter to many different people in different ways that actually it is very difficult to engage with the public and represent everything they are saying.” National bodies are aware of the need for greater public and community engagement and are taking steps to support it.
196.Despite overwhelming support for a national health service, making the case for change based on the benefits for the system does not resonate with the public. Depicting the health service as being in crisis and therefore in need of radical reform does not in many cases chime with people’s actual experience. The Richmond Group in 2014 and 2016 commissioned Britain Thinks, an insight and strategy consultancy, to research the most effective messages and communications approaches for engaging the public in service changes. Britain Thinks found that people are reluctant to label the system as in crisis as they feel it is disloyal. However, recognition that funding and staff shortages are growing creates more openness to change.
197.Britain Thinks found that saving money is not regarded by the public as a justifiable basis for health service reform. Patients and the public need to know how changes will benefit them, their families and friends and their local communities. Focusing on tangible changes to treatment processes or problems that are recognised locally works better. Imelda Redmond, National Director of Healthwatch England, described a good example:
I saw some very nice work done by Suffolk and North East Essex STP. They did all their deliberative events with the public and they could interpret what people were saying. They could understand the difference in life expectancy between Southwold and Jaywick, which are both in their patch—I cannot remember how many years it is—so they could quickly get to, “The public think that is not fair.” Then they can relay back to people in very tangible ways, “We will improve the life expectancy,” “We will reduce that gap,” or, “We will have a zero tolerance on suicides in our patch.” These are tangible things that people get, which is quite a different language to, “We will improve the pathway for people who need tertiary care on blah.”
198.The public also have a strong emotional attachment to local services, particularly hospitals. Hospitals signify safety, somewhere people can go in emergencies and receive expert treatment. For many people hospitals and GP practices are the two access points they rely on. From the public’s point of view any changes to these services are much more “radical” than any of the changes the health community considers radical (e.g. risk stratifying patients). Therefore, it is important the public continue to recognise the services they depend on (hospitals, GP surgeries etc) in whatever changes are proposed.
199.Ipsos MORI explained that there is strong support for ensuring the public is engaged in decisions about local service changes. For example, 44% of the public said that they wanted to have a say on their local STP. Similarly, even though 39% did not want to be personally involved, they believed the public should have a voice.
200.Often the NHS has consulted with the public in a manner which can feel very tokenistic for those involved. As Niall Dickson from the NHS Confederation described:
The history of the health service has, frankly, long struggled with public engagement. The traditional means by which you consulted the public was to have a very firm plan. You took that plan out, you went through a period of time and you either got it through or you did not. The way STPs started was probably not terribly helpful; they were seen as secretive.
201.We heard that the NHS can improve the way it engages by initiating an early dialogue with the public and local groups about the direction of travel rather than waiting until they have a concrete plan. As Niall Dickson described, that could take the form of a conversation which begins with saying “this is the direction we want to go in; these are the trade-offs.” The evidence we received is that the public recognise the need to make trade-offs and are willing to engage in a constructive dialogue. Niall Dickson told us that:
Going forward, there is a real prospect that we can go out and have very grown-up conversations, hopefully supported by local and national politicians, because there are some difficult conversations, as well as ones that explain how the new models of care will work.
202.There has not been a sufficiently clear and compelling explanation of the direction of travel and the benefits of integration to patients and the public. National and local leaders need to do better in making the case for change and how these new reforms are relevant to those who rely on services. The language of integrated care is like acronym soup: full of jargon, unintelligible acronyms and poorly explained.
203.The Department of Health and Social Care and national bodies should clearly and persuasively explain the direction of travel and the benefits of these reforms to patients and the public. We recommend the Department and national bodies develop a narrative in collaboration with representatives of communities, NHS bodies, local government, national charities and patient groups. The messaging should be tested with a representative sample of the public. A clear patient-centred explanation, including more accessible, jargon-free, language, is an essential resource for local health and social care bodies in making the case for change to their patients and wider communities.
204.Making the transition to more integrated care is a complex communications challenge covering a range of different services and patient populations. The case for change must be made in a way that is meaningful to patients and local communities. In addition to providing a clear narrative, in accessible language at a national level, the Department of Health and Social Care, NHS England and NHS Improvement should explain how they plan to support efforts to engage and communicate with the public.
162 Oral evidence taken before the Public Accounts Committee on 5 March 2018, HC (2017–18) 793, Q133 [Sir Chris Wormald]
163 Q262 Nigel Edwards
164 Q150 Dr Augst
165 Ipsos MORI (), Richmond Group of Charities ()
166 London Southbank University, STP analysis South Yorkshire and Bassetlaw STP, June 2017
167 Q93 Dr Nagpaul
169 NHS Providers STP0050, NHS Clinical Commissioners STP0064, Local Government Association STP0027
170 Q230 [Nigel Edwards]
171 Q233 [Professor Checkland]
172 Ipsos MORI ()
173 Ipsos MORI ()
174 Ipsos MORI (STP0104)
175 The Richmond Group of Charities STP0102
176 Ipsos MORI STP0104
177 Q153 [ Kate Duxbury]
178 Q155 [Dr Augst], Q206 [ Niall Dickson]
179 Q154 [Kate Duxbury]
180 NHS England ()
181 Richmond Group of Charities ()
182 Richmond Group of Charities ()
183 Q147 [Imelda Redmond]
184 Ipsos MORI () Richmond Group of Charities ()
185 Richmond Group of Charities ()
186 Q152 [ Dr Augst]
187 Q152 [ Dr Augst]
188 Ipsos MORI ()
189 Q205 [Niall Dickson]
190 Q205 [Niall Dickson]
Published: 11 June 2018