The NHS Big Conversation – is it any good?

This is Blog no 81

With a fanfare of trumpets normally associated with policy announcements rather than a consultation, the Government has launched its Big Conversation on the NHS in England.

It is not the first exercise to carry that title. Almost exactly twenty years ago – in November 2004, the Labour Party ran its own ‘Big Conversation.’ Unlike the current blink-and-you’ll miss-it questionnaire, this was a full-bodied tome consisting of 206 questions on every conceivable aspect of public policy. Its responses were virtually un-analysable! At least we have learnt how to run more concise consultations!

It will certainly be big. Indeed, will this be the first to attract over a million individuals?

But is it a conversation?

To meet that requirement, we need to see a proper dialogue – a two-way exchange of views, with one party reacting to the views of the other. And vice-versa. We understand that there may be meetings with stakeholders, but I’m not sure I have so far seen anything that comes close to the interactions that are needed. What we have seen is the launch of the Change NHS website, a short, pleasant film featuring Wes Streeting and three separate ways to contribute your views.

1. The basic survey. Partly agenda-setting, and partly testing opinion on the ‘three shifts’ that form the core of the Minister’s forthcoming ten-year strategy.
2. Space for storytelling. Gathering experiences of the NHS in narrative form and divided between patients and members of the workforce.
3. Ideas market. Letting contributors propose and respond to an unlimited number of suggestions. (The technical term is Ideation – but I’m not a fan of whoever dreamt that one up!)

There is a separate space for organisations; and a mysterious section called ‘Integrated Health Systems’ which seems to be a misplaced piece of communication to Integrated Health Board (ICB) Managers telling them to get ready to organise some local events, and announcing something called a ‘workshop in a box’ by mid-November. I’m sure they can’t wait!

Let us celebrate the good news

First, having a consultation is undoubtedly a wise and sensible move. It recognises that top-down management by diktat has been as unsuccessful as it has been unpopular, and it may give Ministers comfort if they can show that consultee opinion broadly supports their approach to this most cherished public service.

Secondly, it seems well-designed and well-presented for ease of participation – though the hassle of online registration will deter many potential respondents. The NHS has turned to Think Insight and Strategy – a firm with a long pedigree and a history extending back to the previous Labour administration to do the donkey work, and the scale of this exercise may well occupy it for months to come.

Thirdly, it is very clear in the thrust of its questions. Basically, it wants to know the public’s priorities and preferences and discover how much support it will receive when it tries to implement its already-chosen strategies.

The less good news is that this approach has disadvantages

It feels somewhat tokenistic; an admittedly useful fail-safe (“At least, we asked you!”) but an exercise that is unlikely to tell the Government much that it does not already know.

It will, for example, confirm that the public is deeply upset at the difficulties of securing a GP appointment. But surely The Government knows that full well, and such data as it already possesses will be of a higher standard, through structured sampling and weighting; indeed, it will know in vastly greater detail which demographic groups feel most strongly, and why. This conversation will add volume to the numbers of respondents but this of itself will not add much value to the conclusions.

The best consultations explain to participants the nature of the challenges, the various solutions that may be available to policy-makers and the trade-offs that have to be considered. It then invites stakeholders to choose between options and is honest about the likely advantages and disadvantages of each. Ideally, they are accompanied by Impact Assessments.

You will find no such exposition here. It is as if Messrs Starmer and Streeting assume everyone has read the Darzi Report (See my Blog No 79) and is fully aware of the complexities. True, you are invited to express your reservations about the ‘three shifts’, and presumably thousands of consultees will write in “Have you the money to pay for this?” It is one way to offset the complete absence of any financial element in the exercise.

The ’three shifts’ are, of course pivotal. They are from hospital to community, from analogue to digital and from sickness to prevention. None of them are controversial and were, in fact pursued by the previous Governments. What has dogged the NHS is that its many failures to pay for and deliver its current models of care has distracted it from making progress on these three top-level shifts. It may be fine for Ministers to seek our views on these directions of travel, but any reader of the Darzi Report knows that the parlous state of the service is due to the Treasury’s failure to approve capital spending and disastrous reorganisations that haemorrhaged skills and managerial know-how. There is little point in asking the public about these three shifts. Most people just want Ministers to get on with it.

And where in all this is social care?  Everyone knows that restoring the NHS is dependent upon addressing this long-lasting problem area. Its absence from this consultation is a shame and makes it look and feel just a temporary dialogue. Work-in-progress!

As for the giant suggestion-box, we will surely find every idea ever expressed in the nation’s pubs and coffee-shops. The votes for and against will follow predictable patterns so we will probably see charging immigrants close to the top of the pops once again. Like needles in the consultation haystack, however, there will still be the odd golden nugget that gathers support, and for everyone there is the curiosity to see what others have proposed. The downside is to raise people’s expectations that so many well-intentioned items can be seriously taken forward. Is it just PR?

In summary,

Whilst there is little wrong in seeking public and stakeholder views on these overriding policies, this consultation does not really address the difficulties and dilemmas the Government faces.

Without significant extra funding, the NHS can only do so much without taking money from elsewhere. The reason why the shift to primary care never took place was that it never had enough money and insufficient courage to take resources away from hospitals. Little in what we have seen of the consultation so far will help with such tough trade-offs.

HOWEVER, if the Government can be persuaded to empower local ICBs to consult genuinely on how these ‘shifts’ can be managed in their own areas, then we may have some really meaningful conversations.

I recommend those involved with public and patient involvement, members of Healthwatch, Health Overview & Scrutiny Committees, Patient Participation Groups and anyone sufficiently interested to approach your local ICBs at once. Ask for meetings. There is no need for a ‘workshop in a box’. What we need is constructive co-production of better solutions and a Government that facilitates their implementation.

Rhion H Jones LL.B