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Making difficult decisions to transform local NHS services

Dr Amanda Doyle, co-chair of NHS Clinical Commissioners (NHSCC), discusses the importance of stakeholder engagement and transparency if STPs are to deliver their aims and objectives.

Prioritisation and proposed changes to local NHS services are rarely out of the headlines at the moment. Given the pivotal role they play in making decisions about local healthcare, this means that CCGs have been increasingly finding themselves at the centre of the discussions. 

One of the reasons for this is that changes are frequently seen as synonymous with cuts. While there’s no getting away from the fact that financial pressures and spiralling demand are leading to tough decisions needing to be made in the NHS, the point isn’t to sacrifice quality or cut essential services – it is to find a better, more cost-effective way forward. This is what, as commissioners, we are looking to achieve. It is the case, in many places, that transformation of services, rather than simply delivering more of the same, is needed to deliver the best outcomes for patients. 

Stakeholder engagement essential 

It is entirely understandable that patients and the public are concerned about changes to the health service in their local area and the impact that these will have on their lives. It is also absolutely right that they are properly consulted and given an opportunity to have their say. One of the key messages set out in Making Difficult Decisions, which NHSCC has published in collaboration with the Health Services Management Centre at the University of Birmingham, is to engage with all stakeholders from the very beginning – this includes patients and communities, clinicians, local government officials, politicians, national bodies, and the media. 

With public perception being seen by some as the biggest barrier to being able to make changes, this engagement is essential. The NHSCC report sets out how, currently, commissioners can see a rational case for change drowned out by local opposition before it is properly heard. Hearing about a change in isolation, without knowing the details of what will be taking its place, may lead to opposition which can be difficult to come back from even when the full plan is later presented. 

It is safe to say that concern about lack of engagement is a key reason why STPs attracted such attention, long before the first draft plans were submitted. If they are to be a success, it is crucial that that genuine consultation takes place – and is seen to take place – with stakeholders, including patients, the public, local politicians and clinicians. Otherwise we risk losing the great potential that STPs have to encourage collaboration and bring about transformed health and social care. 

If STPs are to achieve their aims, change is inevitable 

If STPs are to achieve their aims of closing the health and wellbeing gap, the care and quality gap, and the finance and efficiency gap, this will inevitably mean changes to the local health and care system. We need to be able to demonstrate that this is not a negative. 

STPs are aiming to improve outcomes for patients which, in some places, will mean delivering care in a different way. For example, if more stroke or cancer patients were treated in specialist centres then their outcomes could be improved. 

Of course, financial sustainability is also a part of STPs – these give us an opportunity to look at all of our services to see if they are in the right place or whether we are duplicating efforts, and if so whether there is a better way to spend the resources that the NHS has available. Spending resources wisely has always been important, but given the financial pressures and spiralling demand we are currently facing it is more critical than ever. STPs have the potential to encourage collaboration across organisations to find whole-system, place-based, financially sustainable approaches that deliver for patients. But they can’t succeed without support.   

This message is as true whatever the footprint – whether it is STP-level, CCG-level or a completely different scale. As we set out in Making Difficult Decisions, part of successfully engaging stakeholders and gaining support will be around having a proper change management plan which identifies opportunities for improvement and safe cost-effective change – and about having the evidence to back up proposals whether it relates to structural changes or treatments offered. In the case of the latter, this evidence should rightly focus on their clinical value and benefits for patients. The Academy of Medical Royal Colleges has recently launched its ‘Choosing Wisely’ campaign, which sets out a list of 40 treatments and procedures that offer little or no benefit to patients. These are the treatments that we need to stop. 

There are also cases where achieving the best outcome for patients requires them to address risk factors such as smoking and obesity prior to surgery. As a GP, I see first-hand that surgery does not always benefit patients. There is a lot of evidence to demonstrate that not all patients gain improvement in their symptom levels or mobility from undergoing operations such as hip or knee replacements. Things like being overweight and smoking are factors which contribute to poorer outcomes, so it makes sense to reduce those risks before going ahead with surgery. Again, this can prove controversial when introduced, but it’s about improving health outcomes and maximising benefits for our patients.   

In order to get support for changes to the local healthcare system, strong relationships and active engagement with all stakeholders is key – this includes patients and communities, local politicians and local media. Currently this is something CCGs can struggle with, but to make sure that decisions command the confidence of our stakeholders we need to make sure reasons for seeking to do things differently are properly communicated and fully understood. 

Difficult decisions around what services to fund within the finite resources available and how they should be organised are an inevitable part of commissioning healthcare. Patient need is changing and the ways we can best respond to that are changing too. While the decisions may be difficult, they have the potential to take us is towards services and outcomes that are fit for a transformed and sustainable NHS that delivers for patients.

FOR MORE INFORMATION

The ‘Making Difficult Decisions’ report can be accessed at:

W: www.nhscc.org/policy-briefing/making-difficult-decisions

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