Public engagement – pitfalls, barriers and benefits

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Part of The public and the NHS

It is often argued that the intensity of the public’s relationship with the NHS insulates the service from necessary change. However, like any relationship, it is not quite as straightforward as that.

Certainly, recent polling carried out by Ipsos MORI for The King’s Fund once again underlined the strength of public support for the service, with four out of five people (77 per cent) agreeing that ‘the NHS is crucial to British society and we must do everything we can to maintain it.’ Yet, from my experience, users of the service – particularly those who use it regularly – often recognise that it needs to change. If you take the time to ask them for their views, people will explain in clear terms what is working and what needs to improve. It is also true that people are realistic about what the service can and cannot offer if they are engaged in the right way. But, for those in the NHS leading service changes, engaging with the public can feel difficult, especially when potentially unpopular decisions need to be made.  

Since sustainability and transformation plans (STPs) were announced at the end of 2015, there has been a great deal of debate over how much public engagement has taken place, and how effective it has been. 

In our work with Ipsos MORI we wanted to explore the extent to which people want to be involved in decisions about health services. 

Nearly a third of people (29 per cent) said that decisions about which NHS treatments and services are available should be made solely by qualified health professionals. The majority (56 per cent) said that the public should be consulted but that the final decisions should be taken by qualified health professionals, while 14 per cent said the public should be much more actively involved. 

While 14 per cent represents a significant proportion of the population, these findings suggest that, for the most part, people trust health professionals to make decisions about local services. However, the majority at least want to be consulted, if not be more actively involved, so if decision-making is not transparent and people are not at least given the opportunity to engage and comment, then it is hardly surprising if problems and opposition to change arise.  

These results should also make us reflect on the methods the NHS uses to engage people. Open processes, such as public meetings and self-selecting surveys, may provide a biased perspective of public views because they can disproportionately involve those who want to be actively engaged. This means that potentially only the views of small group of people are heard. ‘Who are we not hearing from?’ is a key question to ask. One of the frustrations is that public engagement is a term that is often used to describe a specific process at a moment in time. Effective organisations will be using insight and feedback from users as part of their daily business, using a range of sources both quantitative and qualitative.  

An unhelpful, if not uncommon, view is that the NHS cannot deliver everything people want so there is no point in asking. This can lead to public engagement that feels like a tick box exercise. People sense this and frustration grows accordingly. Effective public engagement is not just about asking people what they want, but exploring what matters to them, what they think would work best and, perhaps most importantly, why. These conversations need to be framed within realistic parameters about what the NHS can and cannot deliver. But the most important thing is to listen. 

And we shouldn’t underestimate the public’s willingness to engage in difficult conversations. While people react badly to the idea of a ‘postcode lottery’ – two-thirds of people (67 per cent) think ‘treatment and services should only be available on the NHS if they are available to everyone and not dependent on where you live’ – we need to delve a little deeper. Qualitative work with the public suggests that people will accept some variation in access to care as a trade-off for more efficient services tailored to their needs. This reinforces the importance of having local conversations.

Where the NHS most needs to improve is in speaking a common language. Too often, it communicates change in a different language to the one spoken by its users. STPs, ACOs (accountable care organisations), ACSs (accountable care systems), PACS (primary and acute care systems) and other acronyms can feel hard enough concepts to grasp for those working in the service. For the public, they can feel impenetrable. People are not, for the most part, interested in the wiring of the system. They care about the end-product – the care that is offered and the experience they have – so changes need to be rooted in how they can benefit patients and explained using appropriate, accessible language.  

Finally, it is worth remembering that users often have very good ideas. It is this insight that should stop the NHS seeing public engagement as something that has to be done, and instead think of the benefits it can bring. If that doesn’t convince you, perhaps it is worth reflecting on the words of Dr Al Mulley, Director of the Dartmouth Center for Health Care Delivery Science, US, at a recent King’s Fund event: in any other industry, not understanding your users would lead to bankruptcy.   

A version of this blog was originally published on HSJ.

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