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Five things the ‘biggest ever conversation about the future of the NHS’ needs to succeed

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The government has just launched Change NHS, ‘the biggest ever conversation about the future of the NHS’. Open to the public, staff and wider health and care organisations it is focused both on hearing from people on what could be improved and on hearing views on the three key shifts that the government wants to make to how the NHS operates (from treatment to prevention, from analogue to digital and moving care closer to home).

It is a welcome recognition that these kind of fundamental changes to the model of care cannot be driven through top–down decisions made in Whitehall. It has to start with those who use its services and those who work in it.

I have been working on patient and public engagement for most of my career and the NHS does not have, with some notable exceptions, a good track record when it comes to listening to or engaging those it serves. Too often patient and public engagement in the NHS can feel tokenistic, something that has to be done while the real decisions are being made behind closed doors. I have lost count of the number of patient and public engagement exercises I have seen that, despite the rhetoric, have been carried out with little to show for it at the end, despite the obvious fact that designing services without the involvement of those who will use them means they are less likely to work. This latest exercise has the potential to change that, to demonstrate that listening to and working with people and communities is part of the solution rather than something that ticks a box. Done well, this exercise can be the start of how the NHS can work differently with the people it serves. So, what would a successful process look like?

It does not limit itself to what the system wants to hear. Too often these exercises focus on questions that the health and care system want to ask. There needs to be space for difficult conversations about the three shifts but equally space for what the public want to tell the government and the NHS. The priorities for many people right now will be for the NHS to get the basics right first: improve access, reduce the waiting list and stop sending appointment letters out the day after an appointment. Yes, we need to understand views on the 3 shifts and the trade-offs that will be needed, but the best exercises are not limited by what the system deems important and instead allow communities to tell the system what it needs to hear.

There is equality of voice. It is an uncomfortable truth that some voices are more likely to be heard than others – health inequalities are widening and we know the voices of some communities are not always heard by the health and care system, as we saw in our recent work on the health and care response to Grenfell. If health and care systems want to build genuine partnerships with communities, they need to build trust. People will only trust those systems if they feel that services are on the same side as them – not part of, or a cause of, the structural disadvantages, including racism, that they face. This exercise has the potential to address this but only if it builds ways of listening that are accessible, inclusive and allow people to provide their views in ways that work for them.

It achieves the right balance between local and national. Nationally driven conversations are important but the engagement work taking place in local health and care systems is arguably more important in the longer term – it has the potential to really change how public services are delivered alongside the communities they serve, something I saw at close hand in our work in Wigan. I am really encouraged to see the approach some areas like the integrated care system in Frimley are proposing to take for this exercise, including asking leaders to leave their offices and reconnect with the communities they serve as well as recognising the crucial role the voluntary, community and social enterprise sector needs to play. This is where the longer-term change will happen, so as much emphasis needs to be placed locally as nationally and crucially local systems need permission to act on what they hear. 

It is clear how decisions are made based on what has been learnt. It is one thing to listen, and another to act on what you have heard. If you are carrying out a listening exercise, then one of the things that you need to do is explain what you learnt and what you are going to do with what you have heard. It is depressing when patients and the public have taken the time to give their views only for them to be ignored. Transparency on how this has informed decision-making and showing people that this is not the end will be key – building on the engagement to start to form genuine partnerships with people and communities.

It drives a cultural change – one that prioritises the voices of the people and communities served by the NHS. One of the tests for this exercise will be the legacy it leaves behind. The timescale for this exercise is tight and we know that good engagement needs to be sustained, not conducted as one-off exercises. Instead, a marker of success will be how this way of working is followed through into how the plans are implemented and beyond. 

As it launches a national listening exercise, the government has the opportunity to lead by example and show how listening and acting can drive the change that is needed. It has the chance to not only show how voice has been built into decisions made for the 10-year plan, but to clearly signal how the NHS can move to being an organisation that is genuinely open to listening to, learning from and working with those it serves.  For all of those who have been championing the voices of people and communities for years now I really hope it does.

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