Filed Under (Hospitals, Localities) by Paul on 30-01-2013
The last few days have seen some very important disagreements about the extent to which NHS hospitals need to be changed. Last week’s Guardian was full of the call for change from Bruce Keogh, the National Commissioning Board’s Medical Director. He took the fight to politicians by saying that by defending local interests MPs risked consigning their local hospital to “perpetual mediocrity”.
This is a sharper way of saying what others have been saying for some time. If politicians stand in the way by leading local campaigns against changes to hospitals they are consigning the NHS in general, and their local hospitals in particular, to falling behind. Medicine is a very rapidly changing service. Hospital services will need to be changed regularly to optimise them.
Unsurprisingly this did not go down well with the politicians who had been leading campaigns to try and hold up the changes that Bruce Keogh sees as necessary.
The MP for Enfield North, Nick Du Bois, who has tried and not succeeded in stopping change at Barnet and Chase Farm in North London wrote a very interesting open letter to Bruce. He said,
“I believe your comments are wrong because you fail to understand that driving change is as much about winning the hearts and minds of the public you serve, as it is about winning a clinical argument on excellence with politicians.”
There is a really important clash of paradigms here.
Bruce Keogh and many other clinicians cannot agree to the status quo when they know it is putting some patients at more risk that a reconfiguration would deliver. Their profession must drive them to argue for change.
But on the other hand the politician’s job is to represent the public. I have spent most of my life with democratic politicians and have much more respect than most of the public for their execution of this task. Many people who don’t understand politics expect democratic politicians to stand up to the public that they represent. And when they don’t they see that as shameful or cowardly.
It isn’t. It is what democracy is all about. When an elected politician fails to take on his local public on a matter of hospital change this is not weakness but strength – of democracy. OK I am sure the NHS might be happy if every MP refused to listen to their local public and went along with what the NHS wants to do, but actually if all MPs did that they would be letting down democracy.
I think the NHS is very important to British society.
But I also think representative democracy is too. Probably – (big deep breath) – more important – even than the NHS. (To make the point more forcibly – much as I love the NHS I would not want to live under a dictatorship – even with a good NHS)
So what to do? It is really important for the public for the NHS to be able to improve quality, safety and value. For that to happen there will need to be very radical changes to hospitals.
The problem facing the proponents of change is that they believe that all the local public are intrinsically against changes that they see as necessary. They think this way because on those occasions that they have tried to bring about radical changes to hospitals, they have had to do so in the teeth of almost universal opposition from the public.
Their assumption is that the whole public, in every locality, will always be against the necessary radical changes for which the NHS will argue.
Their evidence for this is that whenever the NHS tries to make any major changes there is a large campaign against it.
So the evidence that the public is intractably against hospital change derives from the fact that whenever the NHS tries to make such changes the public disagrees.
But the flaw in the assumption that this is backed up by evidence is that the only time the NHS is really interested in what the public thinks about its hospitals is when it tries to change them.
The problem with the logic is that the NHS could be the thing that is causing public anger by the way in which it tries to bring about these changes. The argument goes this way. “If the NHS is only really interested in my views about the local hospital when it is trying to radically change it then we, the public, don’t have much room for manoeuvre.”
My argument is that the way in which the NHS deals with the public and its opinion about change creates this near universal opposition. I don’t believe that the near universal opposition is there to begin with, but is rather created by the NHS’s long term failure to really listen, and its short term failure in the way in which it goes about trying to make change.
Last March I shared a platform at the Nuffield Summit with Shirley Williams. She has been an MP in two very different constituencies. By all accounts she was a good constituency MP and given her political career I don’t think she can be accused of a lack of political will. She was answering a similar set of questions from NHS leaders and she made the point that probably there had over her time as an MP been 6 or 7 attempts at reconfiguration in her constituencies.
Each time the NHS created such a mess of their consultation that on every single occasion the people that came to see her and who asked for her opinion were universally opposed to change.
This meant she was confronted with 100% opposition among her constituents. As she told the conference,
“Give us 20% on the side of change to work with, and it’s possible for politicians to use their leadership skills.”
But no-one. Nothing. Zero. It’s just not possible for a democratic politician to do anything with that level of support.
The answer to this problem starts with much closer attention to what patients and the public say and feel about their hospital. Not just at times of change, but all the time. Listen to what people are saying all the time and you hear a much more nuanced and complex experience of the hospital.
I am suggesting that the public don’t want to keep everything in their local hospital as it is. They would probably like some change and improvement. They just don’t trust the NHS to make it.
And I am suggesting that, for the most part, it is as a result of the NHS not having listened to this complexity before it starts the process of change, that it finds itself meeting universal disagreement.
The time to listen closely is before the changes are thought through, not afterwards.