Planning a service change programme is hard at any time. Differing partner priorities, competing stakeholder expectations, and challenging political environments are just a few of the many variables that demand our attention when we’ve got that blank Gantt in front of us.

It’s no wonder, then, that the first things we reach for are those few old faithfuls we can rely on as the basis of our plan.

I’m talking about the governance, regulatory, and procedural aspects of service transformation programmes that are old friends to those of us who know them well.

These bodies, these laws and regulations have been the bedrock of our service change programmes for the better part of a decade. These have been the things we can rely on in a sea of variables. Lashed together they give us a raft of knowns we can use to steer change in unpredictable waters.

The Health and Care Bill progressing through Parliament will mean these familiar paragraphs, our reliable old faithfuls will change themselves. And small changes on paper mean big changes for major service change and transformation programmes.

Nobody knows better than service transformation leaders that change brings challenges and opportunities. So you won’t be surprised to hear that these are the questions even experienced programme directors, and patient involvement and public consultation leads are bringing to us right now.

So what variables should we be thinking about when we’re planning?

1. Timelines

A service transformation programme timeline is always top of the list when a new programme gets underway. It gives certainty. It shows there’s a plan. It communicates credibility. It can often be approved before the programme director has had a chance to appoint governance, or crucially, patient involvement and communication leads. And that’s a shame, because it’s these factors that often mean the initial plan has to be revisited pretty early on.

In these cases it’s common for the key milestones and deadlines in the plan to be moved, meaning the credibility the programme leadership has gained among senior stakeholders by getting a plan out early, can quickly erode.

Right now it’s external factors, the Health and Care Bill and the NHS response to the COVID-19 pandemic, that are making the biggest impact on plans and timelines. We’ve been helping our clients reschedule their programme timelines to account for the recent announcement that the date on which ICBs (integrated care boards) will formally come into being has been moved to 01 July 2022. A three-month delay on the long-trailed 01 April. A necessary delay and better for all sorts of good reasons, but a delay nonetheless and one with a huge impact on leadership, governance and decision-making.

Moving some programme timelines to an indeterminate point in the future might be possible. Many of the change programmes we’re working on don’t have that luxury, because they are critical and have to be delivered to make services safe and sustainable.

2. Governance

Thoroughly mixed in with the issues the Health and Care Bill brings us for our timelines is a whole pile of governance issues.

Delaying the implementation of ICSs and ICBs from 01 April to 01 July is, we’d argue, necessary in the current circumstances.

Many ICSs (integrated care systems) have no permanent leader appointed as yet and our clinical leaders’ attention is firmly and rightly focused primarily on the pandemic response. And with winter far from over, the question for many of us is: is a three-month implementation delay enough? Should it be delayed again? Another three months?

What does it matter, you ask? Someone is always in charge. There’s always a decision-making body. That’s true, of course. Procedurally there should be a smooth transition – the decision-making body is dead; long live the decision-making body. Practically, though, the people will change. Organisational memory will be affected. Expertise and experience will be lost.

That means the new bodies are unlikely to be as comfortable with the issues as their predecessors. Some will not be as confident with the procedural requirements. Many of the people will be unknown to key external stakeholders critical to the process. All of these affect trust and confidence. All affect the pace at which your service transformation programme can move forward.

Another effect of the changes is that some of those spiky, locally controversial changes – the temporary closures of urgent care facilities, wards in community hospitals, birthing units and the like that had already hung around for ages when they were postponed and delayed by the pandemic and are still unresolved – the effect is that these will be carried over to the to-do list for the new bodies.

Hardly the way for a new body to get off on the right foot with local stakeholders and a reluctance to address them might allow the issues to fester longer.

3. Powers over service reconfigurations

Perhaps the biggest and least predictable of the changes proposed by the Government are those aimed squarely at service reconfigurations. These proposals would give the Secretary of State sweeping powers to intervene in local service change issues. And if proposals published in the White Paper are implemented in secondary legislation, upper tier local authorities will lose their powers to refer service reconfiguration proposals to the Secretary of State for review. Either could mean a massive upheaval. Together they could be seismic.

The proposals for new powers for the Secretary of State to intervene have been hotly debated in the House of Lords as the Bill goes through its committee stage. A raft of important organisations have expressed concern about the lack of detail in the proposed powers and the effect on long-established, proven ways of working.

Of course the proposals will be debated and might be amended. It’s likely there will be new procedures, updated regulations and new guidance. All will take time to develop, publish and embed. So perhaps we should see this as a series of changes over time. An evolution, not an event?

There’s lots being written about the implications of these potential changes. The thing that matters most to those of our clients with service change programme plans on their desks right now is: how will their sometimes unpredictable local health overview and scrutiny committees react to potentially losing their referral powers. There are many delayed transformation programmes already in the system. Add to those a potential logjam of locally sensitive, temporary service changes that were made in response to COVID. If local authorities react to the potential for their referral powers being withdrawn by referring even a small number of the issues while they still can, the system could be swamped.

Thankfully the potential for these changes also presents opportunities. Combined with the opportunities presented by timeline and governance issues, we’re helping our clients resolve issues that they’ve been carrying for too long more smoothly and quickly than they’d ever thought possible, even just a few months ago.

We’ve helped clients overcome long-standing, long-discussed maternity service issues in the Midlands by charting a new course to achieve programme objectives without the need for a controversial public consultation. We’ve worked with clients to secure agreement from local politicians to make permanent highly-controversial changes to a remote urgent care facility in the South West. And we’re supporting systems to chart timelines that resolve other issues before ICSs take over that would otherwise be a dead weight for the new organisations’ leaders to carry.

Sometimes it just takes someone external and experienced like us to spot the opportunities in the challenges change and uncertainty present.

It’s a new year full of new possibilities and I decided to ask our directors, Caroline Latta and Paul Parsons, what they have planned for Stand in the year ahead. Here’s what they had to say.

Caroline: The way we’ve planned has changed since we started. At the beginning there was lots of next-week and next-month planning. Now it tends to be much more next-quarter and next-year planning. So you’re asking us at a good time.

Paul: It’s all about doing more of what we do best: patient and public involvement, strategic communications, and service change programme support for health and care. Helping NHS programmes all over the country solve difficult service change challenges. That’s what we love doing and what we’ve been doing from the start.

Caroline: Yes, whether it’s building entire new hospitals or developing plans for new buildings, reconfiguring urgent and emergency care or maternity services to make sure they comply with the latest standards, or helping with other tricky service change challenges as we’re doing with mental health and community hospital services. We’ll be supporting our clients transform the health and care services they provide to patients.

Paul: We’ve been really lucky to be asked to work on some of the most challenging service change projects. It’s a busy time in the NHS, and we’re proud to be in a position to contribute where help is needed and be making a difference for patients. We have an amazing team and great clients.

Caroline: It’s amazing when you think about where we’ve come from. I think it was Maya Angelou who said “If you don’t know where you’ve come from, you don’t know where you’re going”. So it’s important to us to keep where we’ve come from in mind. Knowing what we’ve achieved helps show us what’s possible.

Paul: This time two years ago, Stand was nothing but a twinkle in our eyes. It was pretty much exactly two years ago, early January 2020, that we were in California and saw the street art that inspired the company name.

Caroline: “Stand for something, or you’ll fall for anything.” It was the essence of all of the conversations we’d had about the values and principles we wanted to base our company on.

Paul: We set up Stand in March 2020. Our first commission was to write a practitioners’ guide to the legal duties for service change for NHS England. Soon we were working on new hospital programmes, supporting public health departments and NHS organisations on their COVID responses, and helping NHS organisations all over the country with their service change programmes.

Caroline: And here we are, thousands of patient contacts, public meetings, focus groups and discussion sessions later, and of course more Zoom, Teams and Google Meet meetings than either of us expected to have in our entire lifetimes.

Paul: What started with just the two of us, is now keeping a team of eleven busy.

Caroline: Sticking to our values and ways of working has been good for us. So, definitely lots more of that this year. We’re lucky to get really positive feedback and several clients have given us the ultimate endorsement of our work by booking us a long way into the future or asking us to take on other projects for them.

Paul: We’re starting the year recruiting new staff and associates to provide the services our customers are asking us for. It’s going to be an exciting year. How have we done? Have we answered your question?

They certainly have.

Happy New Year from all of us at Stand.

Here’s to an exciting 2022!

Hi, I’m Callum and I’m the communications and engagement intern at Stand.

I’m straight out of university and this is my first experience of a professional work environment. My lovely colleagues have asked me to write about my first impressions and the kind of things that I’ve been involved in since joining the company. I can’t say that, when I started at Stand in June, I expected that I would end up on BBC News. Mustn’t get ahead of myself though, more of that later.

Starting at Stand was a massive eye opener for me as to what work can, and should, look like. My experience of work had been in retail, where work was rigidly structured, with a firm line between managers and staff that was rarely crossed. At Stand it’s different. It’s a team approach, everyone is supportive and works together and there is no discernible hierarchy. The environment isn’t entirely stress free, at the end of the day the job needs to be done and done well, but great support and the resources needed to get the job done means there is no undue pressure.

The work I’ve been involved in since starting has varied massively. One day I’ll be helping to shepherd the media around a newly opened vaccination centre, another I’ll be helping to conduct interviews with patients concerning their views on local NHS services, and the next I’ll be taking notes in calls with senior NHS leaders. No two days are the same, and I can’t see that changing in the future.

The stand out moment of my time at Stand so far has to be when I was interviewed by the BBC at the opening of the pop-up vaccination centre at the Centre for Life in Newcastle. I had never been on the TV before, never mind the national news, and I wouldn’t have had the opportunity had it not been for working here. There have been lots of other good experiences too. I’ve really enjoyed the opportunity to sit in on meetings with NHS leaders in the area and to see how decisions are made at the highest levels of healthcare. And I’ve had opportunities to work directly with these leaders and to learn from their experiences, which has been invaluable for my professional development.

As I mentioned, this is my first experience of a professional work environment, so I don’t really have anything else to judge my time here off of, but if everywhere I work in the future provides half as much support to newcomers as Stand has, then I’ll be set for life.

We recently got some feedback that made us think about why we do some things the way we do them.

We paid an invoice from one of our brilliant freelance suppliers by return as we always do and sent a remittance note. A few minutes later they sent a note back:

“Thank you, it is the quickest remittance I have ever received in 9 years.”

It’s nice feedback, but the first time you’ve been paid by return in nine years of trading? It really shouldn’t be that unusual.

Being paid when you’re working freelance should be straightforward: you perform the task, you submit your invoice, you get paid promptly. Your clients want your skills, want the best price and want their work done to a deadline, then some of them make you wait ages for payment.

Caroline and Paul both worked freelance before setting up Stand, so they know that getting paid when you’re working for yourself can be a real headache. Chasing payments is stress you can do without. A late payment can have a big impact on your income and personal finances. Freelancers have to spin a lot of plates and it is easier to do if you know you’re going to be paid on time.

We want our freelancers to be focussed on producing the brilliant work we’ve come to expect from them. And we want talented people to want to work with us. We want our freelancers to have confidence, enjoy working with us and never have to pester us to be paid. So we chase our freelance suppliers for their invoices and we’ve set up our systems to pay them by return.

It’s nice to know that approach is having the effect we want it to.

Version 4

Early last year NHS England and Improvement (NHSEI) updated an update to guidance on merging CCGs that had been in place for three years. The updated guidance took account of the vision set out in the Long Term Plan for streamlined commissioning arrangements that align with sustainability and transformation partnership (STP) and integrated care system (ICS) footprints. A trickle of organic applications became a wave as CCGs were encouraged by their regional teams to make applications to merge in line with the Long Term Plan and as a simple way of achieving administrative savings targets they’d been set. The high volume of mergers has provided the opportunity for some learning and NHSEI has incorporated that in an update: Procedures for clinical commissioning groups to apply for constitution change, merger or dissolution, Version 4.

The reality is that the procedures in this guidance has remained pretty much unchanged since it was first published in October 2015. NHSEI took the opportunity to incorporate learning from the first CCG mergers in a Version 2 (Nov 2016) and the strategic policy changes forced version in April 2019.

As its title sets out, the guidance covers three procedures:

• Procedure to change a CCG constitution
• Procedure to agree a CCG merger
• Procedure to dissolve a CCG

The body of the text in each of the procedures sections of version 4 receives only minor tweaks, that will provide greater clarity for CCG leaders sitting down to find out what they have to do. The most common change is from an assumption that approval from CCG governing bodies is required, to specifying that the approvals needed must be in line with local governance arrangements as set out in CCG constitutions. That might be the full membership, a subset of the full membership, or the governing body. The revision team has also added in the mergers section a nod to the ‘Shropshire approach’, noting that “Mergers involve both the dissolution of existing CCGs and the establishment of a new one.” The stakeholder engagement and consultation requirements for the process are unchanged by this version.

The real changes are about the information required to make an application to merge CCGs sit in annex 3 – merger application requirements.

A first draft of the proposed new CCG constitution has to be included with the application. As it’s still an application, the draft need not yet have been approved by the members.

• The requirements that must be covered in the financial strategy or plan are itemised for the first time; and
• The elements CCGs are required to cover in their clinical commissioning strategy are also set out where they weren’t in version 3.
• The wording in the annex now notes that NHSEI will, quite reasonably, expect documents to be more developed the closer to merger date they are submitted.

All in all these are positive updates to guidance aimed at smoothing and speeding up the process of applications to merge CCGs.

Planning a communications and engagement programme to assist the application and support its implementation can be an onerous task. Our team brings the learning from several CCG merger programmes. We’re always happy to share, so get in touch.

The global pandemic has created a new norm in terms of shifting involvement activity to digital methods and it’s important to recognise that a large majority of ‘traditional’ face to face consultation activity can be replicated online.

An unintended benefit of social distancing is that there’s also been an improvement in the attitudes and abilities of citizens interacting online, so they are better equipped and more familiar with the process of using the technology.

Organisations need to adopt a ‘digital first’ approach which encourages digital engagement without stifling the ability to participate offline, providing an inclusive and blended experience.

There are a number of benefits to digital first. It can make better use of resources – people, time and funding – but the reality is that it does require up front investment in digital technologies, it needs staff training and capability, and it can alter the dynamic of conversations and interactivity.

There’s never a better time than now to get going with digital techniques, using the post lockdown period to reflect on what to keep doing digitally and what must revert back to normal, if indeed normal as we knew it ever returns.

Planning your digital engagement

Just like we do for any involvement activity, having clear objectives, planning engagement activity with stakeholder identification, clear questions and collection of feedback and reporting output and insight remain just as important as ever.

But getting going can be the hardest part.

These are the top things to think about make your digital engagement a success.

1. A Stakeholder Relationship Management (SRM) system.

An SRM is a single digital repository for all stakeholder communications. It is a data store of activity (interactions), feedback (from all channels) and allows you to store, recall and analyse information quickly and easily. It can also be used as a database (e.g. for statutory consultees) and some products have stakeholder mapping functionality, enhanced reporting functions, surveys and event management built in.

Unlike CRM, SRM is concerned with what is being said as well as who is saying it.

2. An engagement portal

Making sure your website has the right functionality and is engaging enough to really harness the benefits of the channel.

With good website development a traditional listening paper or consultation document could be created with multimedia excerpts (collateral) around challenges, explore evidence and provide views. This could include ideas generation, the ability to submit new solutions, for others to comment and rate these and for people to see the conflict and consensus. It can also be a portal through to virtual engagement sessions such as deliberative events.

At Stand we love our work. It’s really satisfying to know our efforts mean the voices of the public are heard and better informed decisions are made. We love learning from others and sharing our learning with clients, colleagues and our wider networks through our blog and resources.

So it was a real privilege to be commissioned by NHS England and Improvement (NHSEI) as expert practitioners to write a short guide to the legal requirements for making changes to NHS services in England. And we’re beyond delighted that NHSEI has published the guide to help service change programme managers plan the steps they need to take to meet the statutory and public law duties.

The commission came in response to research that told NHSEI that service change leaders wanted clearer information about which legal requirements applied when, so change programme managers could plan more effectively to meet those requirements.

Working with Peter Edwards from Capsticks for specialist legal input, we split the guide into six easy to understand sections. The sections align to the steps in the service change process model NHSEI describes in its service change and assurance guidance. Each section sets out the points from legislation and previous legal judgments that service change programmes must consider and address as they progress from exploring service change possibilities to working up defined change proposals to making decisions about which changes to implement. Of course patient and public involvement features heavily and we’ve included useful sections on working with local authority scrutiny and consulting the public when needed.

Stand director, Caroline Latta said, “We’re delighted to have been commissioned by the NHSEI national team to create what we believe will be a helpful document for NHS transformation leads as it brings together for the first time the legal requirements for NHS service change.

We’ve brought our years of practitioner experience to the drafting and are pleased to share what we’ve learned in dozens of NHS service reconfigurations, including judicial reviews in the high court and the court of appeal as well as referrals to the Secretary of state for Health and Social Care and subsequent reviews by the Independent Reconfiguration Panel.”

Peter Edwards, of Capsticks said: “Based on my work nationwide with service change programmes I’m confident that this guide will be a welcome addition to the resources available to programme managers. It will help them to understand and comply with the relevant legal duties, which in turn aids better decision-making, as well as reducing the risk of legal challenges. Ultimately it will support the important work going on throughout the NHS to configure health and care services to best meet the needs of patients.”

Legal duties for service change: a guide is published by NHS England and Improvement as part of a suite of resources available on its FutureNHS collaboration Platform.

One of the challenges of planning a process of making decisions about health services that involves a public consultation is that the consultation takes centre stage.

Perceptions about how long a consultation should last can dominate, leaving little time in a programme timetable for the important work of  preparing for a consultation and acting on its outputs.

The days of closing a public consultation one day and making a decision the next are long gone, now even timescales of four to six weeks between a public consultation closing and the scheduled decision-making meeting are often too ambitious.

Commissioning deadlines, fragile services, operational needs, the push for tight timescales is understandable, but there are good reasons to push back. There are better places to look if you need to save time. Updated regulations and guidance, and Judicial Reviews have all had their impact on the way we do things – giving too little time to do the basics can risk all the, sometimes years of, hard work that’s gone into the programme.

Affected by optimism bias^[1], consultors regularly commit to timescales that don’t allow enough time to do things properly. It’s such an important issue that I single it out in my own planning framework and devote time to discussing it on the dedicated health service version of the Conducting a Public Consultation training course I run for The Consultation Institute.

These are some of the key points to consider:

1 Decision-makers must have time to consider the points raised in response to the consultation. The famous Gunning Principles^[2]state: decision-makers must conscientiously consider the product of the consultation. It’s impossible to do that if the output report is not available or is incomplete at the time of the decision-making meeting.

2 – Change programmes have to allow enough time for consultation responses to arrive and be included in the analysis. That’s straight-forward for online responses, but COVID-19 means we’re seeing increases in postal responses and greater reliance on voluntary and community organisations reaching out to their communities. Timings need to allow for those submissions and reports to arrive and time to get them to the analysts.

3 – Analysing feedback to a consultation on major service reconfigurations is complex and resource intensive. Change programmes need to allow time for that to be done properly and for issues to be identified and resolved. Consultees can expect their arguments to be heard, interpreted fairly and taken into account by decision-makers.^[3]

You’ve got the report now, so you can send it to the decision-makers and they can get on with it, can’t they? No.

4 – In England, the guidance that accompanies the local authority scrutiny regulations says it’s sensible for affected local authorities to have the benefit of feedback from the public consultation to inform their response to the proposals. And it is. So you’ll have to publish the consultation output report. Allow the local authority (normally a health overview and scrutiny committee or joint committee) time to formally respond and ask questions about the proposals, then consider their response in private. This and report drafting can add weeks to the timescale, so change programmes will need to agree that with the individual committee or joint committee they are consulting. Local authorities are statutory consultees in these matters, so their view needs to be conscientiously considered in the papers for a decision-making meeting.

5 – At this point change programmes might need to allow time for regulatory checks^[4]. Programmes are normally informed before public consultation starts if this check will be needed, so there’s plenty of time to plan for it. And the checks can run in parallel with other post-consultation work.

6 – Timeframes need to consider normal organisational processes. If your governing body or board of trustees normally publish meeting papers a week ahead of a meeting, it should do for this type of decision too.

NHS service transformation programmes in England normally reach the conclusion they will need 12-20 weeks between the close of a public consultation and the scheduled decision-making meeting. There are efficiencies to be had. And more complicated programmes often need to be more generous with consideration periods.

 

[1] It’s a thing, check it out.

[2] R (Gunning) v Brent London Borough Council (1985) 84 LGR 168

[3] p306, The Politics of Consultation, Jones & Gammell, The Consultation Institute 2018; R (ex parte Kohler) v The Mayor’s Office for Policing and Crime [2018] EWHC 1881

[4] 4.4.2, Local Authority Health Scrutiny, guidance to support Local Authorities and their partners to deliver effective health scrutiny, DoH 2014

[5] In England: p32 Planning, assuring and delivering service change for patients, NHS England 2018