Feature

Consultation: turning a deaf ear to the public

If the goal is a more participatory and democratic health service, then last year’s ‘consultation’ on the first wave of NHS trusts was a step in the wrong direction, says Christine Hogg

Consultation is often an empty activity. Managers go through the procedures in order to make closures or changes. They respond defensively rather than listen. From 1974 community health councils had one lever of power: the right to be consulted and to veto and delay decisions on closure. However, real consultation happened earlier. Some CHCs found it more effective to be involved in planning. As closures and crises increased, many CHCs felt that consultations tood up all their time and left them frustrated and powerless. Financial constraints meant that even the most well meaning managers felt they had no choice.

Since then consultation has been ‘deregulated’. CHCs’ rights have been limited and health authorities can now determine the form, content and length of consultation, where in the past the Department of Health laid down guidelines. Despite the ‘deregulation’ of consultation, the DoH stresses the importance of ‘involving the consumer’: ‘True consumer involvement is more than just a consultation exercise to “rubber stamp” a decision a DHA has, in effect, already taken. It involves DHSa in taking the initiative in forging links with their local communities in advance, before there are controversial plans in the offing’. And in its guidance letter to managers, the management executive points out that ‘the principle should be ensure a full degree of involvement by interested parties, including consumers, at all stages of strategic and operational change’.

Consultation about the first wave of applications for trust status followed the established pattern. A ‘second wave’ of hospitals is now applying for trust status and consultation taking place between May and July 1991. The first wave of consultancies were rushed, with the glossiest of brochures printed within a few weeks of the NHS Act coming into force. Now managers have plenty of time to plan how they will consult the public.

Last year’s experiences teach us what to look for this time round. There are four basic standards for public consultation in the health service, as defined by a number of legal rulings. These are:

• the information provided should be adequate to enable informed comments;
• the information should be widely available;
• there should be sufficient time and opportunity for people to make comments;
• the views expressed in consultation should be taken into account in eventual decisions.

Information provided

Many of the trust applications were promotional brochures, not consultation documents. They attributed to self governing trust status ‘benefits’ which are due to take place anyway, such as particular capital schemes or funding according to workload. They also claimed benefits of quality which should be achieved by good management in any unit.

The gaps in the documents were revealing and provide opportunities for effective campaigning.

• Quality was discussed like a commodity to be purchased, but there were no detailed proposals of how standards would be safeguarded, in particular in ensuring co-ordination between hospital and community and local authority for discharge arrangements and continuing care.
• Priority was to be given to meeting ‘individual need’. The fact that it is the articulate middle classes who tend to have their needs identified was ignored. No applicants considered how to target services to vulnerable groups who are slipping through the net.
• Trusts may exacerbate the fragmentation between health and social services. Trust applications should demonstrate the lines of communication and collaboration have been negotiated with the local authority, family health service authority, GPs and directly managed units. There was little evidence of this.
• Despite the rhetoric about community involvement, there were no proposals for developing new channels for communication. Non-executive directors were seen as the link to the local community, though their role was not defined. For trusts to survive and attract business, they may in fact have to sever links with their local communities.
• Self governing trusts will not have statutory links with CHCs, which were mainly ignored. Some failed to mention visiting rights for CHCs and other community groups.
• Public access to information and attendance at meetings were not mentioned in most documents.
• The financial information was optimistic and inadequate. There is provision in the NHS and Community Care Act for trusts to become bankrupt … a frightening prospect for the local community. The government may be facing the reality of trust viability with more honesty than many applicants. The information provided in the consultation documents was not sufficient to predict financial performance.
• Success in the internal market is dependent on taking away business (ie patients) from another NHS hospital. No trusts specified the hospitals from which they planned to attract patients, and in some cases the applicants were in competition with each other.

Distribution of information

The NHS management executive has advised that a range of interests should be consulted formally, yet the availability of the full consultation document varied greatly. One regional health authority asked us to return the document when we had read it.

Most but not all applicants also produced summary leaflets for wider circulation. In Brighton the leaflet was distributed to every household. In other areas the summary had limited distribution and the RHA relied on the CHC to do this. A few leaflets were produced in minority languages, but generally towards the end of the consultation period.

The main gap in consultation was with voluntary organisation and community groups. Many RHAs relied on the CHC to undertake this for them, though this is not in the spirit of the guidance laid down by the management executive. Trent RHA consulted only the CHC and the local council for voluntary service. As a result only four responses were received from voluntary groups. In contrast, Yorkshire RHA consulted widely and received 3,154 replies from individuals and organisations. If the RHA is relying on the CHC for distribution, this should be discussed in advance and resources provided.

Opportunity to comment

People must be given the time and opportunity to state their views. In many areas consultation covered the summer when people are often on holiday, effectively reducing the consultation period from three to two months.

Public meetings were generally organised by the CHC. In a few areas applicants held meetings, but they seem to have been poorly organised with low attendance.

Ballots were explicitly excluded from the consultation process by the Department of Health. Many campaigns groups undertook ballots to staff and public and found them a good way of raising the public profile and enabling people to express a view.

Staff meetings were held in almost all areas. There was some criticism that they tended to be aimed at eliciting support and targeted at the professional staff.

Decision making

Those undertaking consultation must be prepared to adapt proposals in response to comments. RHAs need guidance on how to present the comments they collect.

In retrospect, it seems unlikely that all the effect put into campaigning had nay influence on the outcome of individual applications. It may have had more impact in alerting the public to the problems emerging in the NHS, and it also brought CHCs, staff groups and user groups together.

A lot of effort was put into opposing trusts, often with the British Medical Association in the bizarre role of cheerleader. Decisions do not seem to have been made on the basis of comments or popularity: the eight rejections were apparently unrelated to staff and community enthusiasm or the amount of local lobbying.

Is it worth bothering for the second wave? If we are trying to build a more participatory and representative health service, the answer has to be yes. If the public shows a lack of interest, managers will become more and more out of touch and everything can be justified by apathy. It is important that the public shows it minds about what happens to the NHS.

This article is based on research undertaken by Christine Hogg and Paul Martin for the Greater London Association of Community Health Councils with funding from NALGO. Copies of the report The future of consultation in the NHS are available free from GLACHC, 100 Park Village East, London NW1.