Moving from options development into a public consultation period is one of the most challenging aspects for any strategic change programme.

Stand’s director, Caroline Latta, shares four key considerations to have in mind when planning your consultation timeline.

Picture the scene. You’ve worked hard with clinical teams, commissioners, stakeholders, patients and partners, and there’s strong consensus on the business case for change.

Together, you’ve developed great working ideas, developed and applied evaluation measures to include the elements that are important to staff, patients and the public.

And you’ve finally got a robust set of proposals. You are ready to move into the public consultation phase.

You may as well try and nail down jelly. 

Mapping out a public consultation strategic timeline, bringing together all the threads of planning from your options development phase, is one of the most daunting tasks for any change programme. 

The need to delicately balance the timing of multiple aspects of the change programme can be a kaleidoscope of interlinked issues. 

• Is the timing of NHS regulatory assurance, organisational governance, and consultation with health scrutiny committees lined up? 
• How long should the live public consultation period be? 
• Should it be longer to take holidays into account? 
• How much time is needed for drafting and signing off of consultation documents, accessible formats, surveys, focus groups? 
• At which points do key stakeholders need to be involved? 
• What is the best timing for the schedule of public events? 
• And are key leaders available to front them? 

With so many moving parts to align, getting back to key principles is the best way to create a clear roadmap through to the final end point of decision making. 

Map it out and write it down

Start by setting out a timeline, adding in key milestones such as those above and share it with your programme team. 

Include key meeting dates such as boards and committees, include preparation timescales, map out the public start, middle and end dates, when key public events or other research methods could take place. Add in the post consultation timeframe paying attention to when the analysis of feedback would be available and dates for consideration of feedback and decision making.

Gain feedback and contributions from colleagues so that everyone can agree and sign up to the timeline as being realistic and achievable.

Now we have deadlines to focus on and move the programme forward.

Governance trumps all

Public consultation is about making better decisions, so it stands to reason that the governance framework for decision-making is paramount. It provides the statutory legitimacy for decision-making and accountability to the public.

Be crystal clear about how the programme governance works in relation to the decision-makers and other statutory partners. For example:

→ The transformation programme board recommends the final business case to the provider trust.

↪ The provider trust wants to sign it off, before it’s submitted to NHS England and Improvement for assurance.

↪ NHSEI assures the business case and returns it to the statutory commissioners

↪ The commissioners approve the business case for public consultation. 

In simple terms, making sure the right schedule of meetings are at the right time and in the right order to pave the way for assurance and agreement.

Right now decision-makers are Clinical Commissioning Groups (CCGs). That will change on 1st July, when the Health and Care Bill gains Royal Assent when Integrated Care Boards (ICBs) will take over. That means decisions based on a consultation that starts now will be made by your ICB. 

So it’s wise to involve your ICB leaders at the earliest stage you can, because they will need to be satisfied that the duty to involve patients and the public in developing the proposals, the public sector equality duty, and all the other legal duties that come with a public consultation on a service change proposal have been met.

Remember the statutory duty to consult with Health Overview and Scrutiny

Working out the best way to discharge the statutory duty for NHS commissioners to formally consult a local authority on substantial changes is best done in partnership with health overview and scrutiny (HOSC) officers.

They can offer sage advice on how to ensure elected members are involved in the right ways. It’s worth remembering that with local authority elections in many parts of England taking place in May 2022 may mean changes to HOSC membership – so all the hard work you’ve done to develop relationships and gain understanding about the case for change might need to begin again. 

The critical dates for the HOSC are the date by which the local authority must respond to the consultation proposal and the date by which the NHS body intends to decide whether to proceed with the proposal – and it is the NHS’s responsibility to publish these dates and any changes to them.

Forward thinking change programmes will have worked with elected members during the business case development phase, making sure councillors had an opportunity to fully explore the issues in advance. Committees will be interested in communications and involvement aspects of the consultation so it’s always a good idea to ensure you share those plans and provide an opportunity to influence them. It’s likely the committee will wish to have their formal consultation meeting with the NHS on the proposals a few weeks into the live public consultation so they are able to observe the live phase underway, noting the questions and concerns from the public. 

As the HOSC will need to provide a formal response about the proposals to the commissioners, allowing their views to be taken into account at decision making, the committee will likely wish to hear the public consultation feedback to inform their thinking – all extremely important dates that should be agreed with scrutiny officers and mapped into the timeline.

Accept the timeline will keep changing

At Stand Towers, we know how hard managing a consultation timeline can be, and we want you to know that the timeframe for every single consultation we’ve worked on over the last 20 years has changed in some way, manner, shape or form after it’s been nailed down and approved.

It’s inevitable because of the multiple forces outside of the programme’s control. So let your timeline breathe a little. Build in practical contingency from the start and know what impact a change here or there will have on the whole programme. HOSC asks for an extra meeting. Your assurance team asks for amendments that will take an extra week. A key governance meeting is postponed to deal with system pressures. What impact would those have? Preparing will allow you to better manage those bumps in the road, adding flexibility and the opportunity to adjust without busting the timeline completely.

You know how it is. You’ve worked hard to get your change programme off to a good start. Scope agreed. Objectives endorsed. Budget approved. Clinicians are actively engaged and you’re getting a great response to your patient involvement activity. Everything appears to be swimming along nicely.

Then, at an open engagement event, in response to tenacious questioning from a local campaign group concerned that this conversation spells the end of their much cherished hospital, one of your leaders (the chief officer perhaps) drops the C-bomb.

Consultation.

“We’re a long way from any decisions about this.”

They’ve started well.

“We’re here to get your input, to understand things from your perspectives as patients.”

There’s the focus on the process you briefed them on.

“That will help us work out what might be possible. This is just the start of our process. We want you to be involved from the start. That’s why we’re here.”

Brilliant. We got there without using the double-down position. You can breathe again.

 “And of course, we’ll consult you before we make any changes.”

Arrrgh! There it is. Boom! The genie is out of the lamp. A few weeks of well-planned informal engagement and data gathering becomes a much larger exercise.

It’s not uncommon. We’ve had conversations with two change programme teams in the last fortnight that have unwittingly made the promise. And we don’t blame anyone for stumbling into the trap.

There’s a common understanding in the NHS, in England in particular, that there’s a statutory duty to consult the public on changes to services, and making a public statement to that effect hardly seems a stretch, if that’s the case.

Too bad then that it isn’t.

We always start our briefings and development sessions for NHS leaders with a few range-finding questions. These are busy people. Our executive directors, chairs and board members. Their time is extremely valuable, so we want to make sure the 45 minutes they’ve given us are well-used. We don’t want to spend a second of it telling them things they already know.

One of the questions we ask (spoiler alert for future attendees) is:

Who in the room is aware that NHS bodies have a duty to consult the public on service change? 

Sometimes the room knows what we’re getting at immediately and quickly assures us we can move on.

At least half the time there’s a chorus of nods. Then we spend some time unpicking that understanding.

It’s a duty to INVOLVE individuals who use the services and individuals who might use the services.*

And the legislation gives us a handy definition of how we can do that: “by being consulted or provided with information or in other ways”.

In. Other. Ways.

We’re on record countless times as big fans of public consultation and we’re big supporters of the Consultation Institute. Done well on the right subject, it’s a powerful tool for explaining publicly the complexities of the services we provide and making sure everyone who wants a say in changes to those services has their views taken into account.

But the programmes that need what’s often called “full” or “formal” consultation tend to be the big and potentially controversial ones.

“In other ways” gives us the scope to take a proportionate approach to these exercises. We can use innovative approaches to involve the people who have lived experience of our services, and the people who are most likely to need to use them in the near future helps us develop and improve them, or deal with challenges.

The factors which may mean that a public consultation is required for your programme are complex and varied.** The most obvious of them is making a promise to consult stakeholders or creating an expectation that we will. So let’s avoid that.

When we enter a proposal-development process with a properly open mind, we don’t know what change proposals will emerge at the end, so we don’t have the information to assess whether a public consultation will be required.

In practice, the change proposals might be much smaller than the original aspirations.

By talking to service users, an aspiration to close an urgent care centre might become a proposal to require people to access the centre through 111. But if you’ve told your stakeholders you’ll consult them before you make any changes to the service, you’ll still have to formally consult them on that much smaller, possibly less controversial change, or you’re likely to end up in a judge’s bad books.***

So let’s ban the C-word from our service change programmes. Let’s keep it for the times we need it. When we’ve involved people in developing our proposals. When those proposals have been signed off by the board. And when the need to hold a public consultation on those proposals has been properly considered.

Until then get a jar ready and collect a pound a time for your favourite charity.

That’s our proposal. What do you think?

P.S. If you’re looking for a standard alternative phrase, try this: All our decision making is subject to appropriate patient and public involvement. You’re welcome 🙂

Blog by: Paul Parsons

 

*s242/13Q/14z2 of the NHS Act 2006 (as amended). There are some additions coming in the new legislation.

**(See 6.2 Deciding to consult the public in the legal duties for service change guide Stand’s directors wrote with Capsticks for NHSEI.)

*** See Buckingham v Corby CCG 2018.

In a week of heart wrenching stories from Ukraine filling our social feeds, a little nugget of NHSEI (NHS England and NHS Improvement) news was enough to bring a little light into my day.

That news? The NHSEI system transformation team launched a new interactive handbook for service change.

Granted, the list of people this news will bring joy to is a short one, but for this dyed-in-the-wool service change anorak, any new document on health service change is exciting.

Major Service Change: an interactive handbook sets out in 83 pages the context and process of service change in twelve easy-to-read sections. Together they chart the course and requirements of a service change programme. And it links directly to an enormous resource of secondary documents in a whole new indexed resource on Future NHS (*if you’re not a member, sign up).

So what’s new? Well firstly, it’s important to point out what’s not new: all the current guidance and law stands. And the 2018 planning, assuring and delivering service change for patients (PADS) takes pride of place in the handbook’s main list of key resources. Of course we’re proud to see the guide on legal duties for service change, Caroline and I wrote with Capsticks for NHS England in 2020, also on that shortlist. The handbook explains it’s written in February 2022 based on legislation and guidance that applies now. The introduction acknowledges there will be changes when the Health and Care Bill becomes law, so we can be pretty sure there’s an update draft already waiting in the wings for publication in a few months’ time.

The most obvious development strikes as you click on the index. An introduction and eleven stages of service change that expands the six-stage summary process that’s illustrated in PADS, and we’ve relied on as the basis of our plans for years. 

The first of these stages is ‘Drivers and context’, which points to the rigour needed to give your change programme a solid start. Including an important message to start by developing a solid understanding of the situation and challenges. Every change programme has a starting point and the handbook encourages us to know where we are now in detail, before we start working out where we should put our new Hyper Acute Stroke Unit, how many Urgent Treatment Centres we need, or whatever other change programme we are working on.

The handbook helpfully splits the NHS assurance process out into its three stages and sets them out at the relevant points in the process. This means readers get a much more accessible explanation of the requirements of each assurance point than has been available before. That’s going to be incredibly useful to people who are coming to service change for the first time.

Proposal development and options appraisal approaches are under ever increasing scrutiny from the public and local politicians, and we’re given much more detail about these than we’ve had before. And by setting out an eight-month process for planning, preparing, delivering and reporting on a public consultation, the document gives change programme planners a handy and, I’d argue, reasonable insert for their timelines. This gives me hope we’ll see fewer programme timelines arriving on communications and engagement colleagues’ desks with a three-month non-negotiable window to do everything.

Each section of the handbook treats us to an impressive bank of helpful documents. There are case studies, example cases for change documents, webinars, example pre-consultation and decision-making business cases, slide decks on important aspects of the process, and we’re given links to external web-based resources. 

All in all it gives us more than 1200 pages of additional documents, that together look uncannily similar to our own resource library. On top of the legal duties guide in the key resources section, we’re pleased to see a webinar Caroline and I did for the transformation team in October 2019 on planning and conducting a public consultation included in the public consultation section.

And among these hundreds and hundreds of pages, it’s nice to see the return of some old favourites like the previously underused and under promoted Toolkit for communications and engagement teams in service change programmes, which by mishap or design seemed to have disappeared from the public website in 2019.

Inside the sections, I have a few questions about some of the drafting choices that I’ll pick up with the team. And a concern or two that the very accessible language and layout might mean some programme leaders less familiar with these processes might underestimate some of the requirements. These are minor points. 

Overall the document is a triumph. It’s clear to see the effort and commitment that’s gone into developing the handbook. It’s a huge achievement. It shows in one place the complexity involved in running a service change programme and the breadth of the considerations that need to be taken into account. It will be invaluable to change programme leaders across the country including the service change programmes Stand supports.

Congratulations to the transformation team and everyone involved in bringing this together at NHSEI. It will be a game-changing resource.

Oh, and the handbook tells us an addendum to PADS will be published shortly, so brace yourself for more excitement from Stand Towers!

Blog by: Paul Parsons

The COVID-19 vaccination programme has been the runaway success of the UK’s response to the pandemic.

Stand were asked to support the North East and North Cumbria’s COVID-19 Vaccination Programme, providing strategic communication and involvement advice and operational support to the vaccination programme’s leadership team. The mission – to vaccinate as many people as possible, as quickly as possible.

Stand’s director, Caroline Latta, shares her observations on the wider learning for communications and transformation professionals from the fastest and most successful vaccination rollout in the history of the NHS.

 

Relationships count

It’s a universal truth that relationships count, things get done through relationships and trust.  The vaccination rollout has proved that strong relationships make all the difference, both building on those already there and developing new ones, when it comes to getting things done quickly.

The extensive network and professional relationships we’ve built over twenty years working with NHS and public health colleagues across the country are particularly strong in the North East.

Joining the regional COVID-19 Vaccination Programme, hosted by Newcastle Hospitals, six months into the pandemic, we knew that relationships would be the key to the success of the programme. Building and sustaining them through trust and open communication was made a priority in our strategy.

Time and again in the tight spots, when it looked like what we were attempting was about to prove it was impossible, those relationships delivered.

 

Everyone is a leader

Everyone at every level was a leader in the vaccination programme. No single partner, person or place was more important than any other. Everyone at every level had their role to play.

From the outset, the vaccination programme took the view that it is local leaders at all levels who make things happen. It was the regional programme’s role to co-ordinate and to filter the important clinical policy and key message must-dos from the loud noise of mass information overload. Our job was to support clinical commissioning groups, primary care and local authority public health leadership to stand up local services, quickly.

Lots of leaders in a rapidly changing environment needed up-to-the-minute sources of information they could trust. Our large engagement events, often with hundreds of attendees, were open, honest and transparent where programme leaders would respond to unfiltered questions and listen directly to the challenges being faced out in the field.

The approach meant local councils, hospitals, GPs and community networks could work together extremely closely to reach as many people as possible for their vaccination.

 

Single clear messages for cut through and amplification

 It was vitally important at a time of national emergency, with so much fear and uncertainty in relation to the pandemic, that public confidence in the NHS’s ability to deliver vaccination to the full adult population was established and maintained.

The national strategy saw single clear messages about who was eligible and when, balancing the pace of national rollout and vaccine supplies, no easy task.

While sometimes there wasn’t the clear forward view of when new age groups would be announced, it was right that this was nationally controlled.

The benefit of this was a sense of fairness and equity for the population which enabled a high level of cut through of messages.  National, regional and local media reporting the same messages, consistently amplified through local authorities and NHS organisations’ social channels.

This made it easy as possible to act with a single voice and have clarity on what was being asked by the national NHS vaccination programme team and government, and a clear call to action for the public.

Newcastle Hospitals was one of a handful of centres across the country to vaccinate the first patients on 7^th December 2020 and opened the country’s first large vaccination centre at The Centre for Life soon afterwards.

The regional and national media have supported every single milestone, from opening new large vaccination centres, mobile services and new age groups opening up. Made possible by the willingness of the vaccination programme leaders to step forward to be interviewed, supported with clear messages and briefing.

 

The importance of good data

 At the outset of the vaccination programme, the availability of good data was limited. This changed rapidly, with data becoming available to allow the vaccination uptake to be viewed in real time. This allowed regional and local vaccination leaders to identify the areas where vaccination uptake was lower, understand communities were affected and take action. Through the leadership of the Director’s of Public Health, the different approaches taken to address inequalities and to engage people from underrepresented groups were mapped across the region, captured by geography and population group. A catalogue of information demonstrating a wide range of different interventions was developed to share good practice. Importantly, four key learning points are transferable to inform future planning for COVID-19 and other vaccination programmes:

1. Better information for communities and professionals such as alternative language, easy read, etc
2. Increasing accessibility, taking the vaccine to the people
3. Empowering communities, using community champions and other trusted voices, and
4. Partnership working and collaboration, linking with businesses and the community and voluntary sector.

 

Reflections

The pandemic response has highlighted as never before the value of communications and engagement as a strategic function in NHS organisations and public health departments. Nowhere was that more evident than in the rollout of the vaccination programme.

It was never going to be an easy task. The foresight of programme leaders in the North East and North Cumbria to put strategic communications and engagement at the heart of the programme meant it was as smooth as it could be, with many challenges quickly resolved and others identified and avoided before they occurred.

Over the course of the rollout, the regional vaccination programme itself, with the support of local authorities, opened seven mass vaccination centres who were able to vaccinate thousands of people a day. The sheer volume and geographical spread of primary care networks, hospital hubs, and later, community pharmacies, saw nearly 300 vaccination outlets that have provided over 6 million first, second, booster and other doses in-line with JCVI advice.

See more on our work with the COVID-19 North East and North Cumbria Vaccination Programme

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.