Changing the NHS – The need for a new Skills Mix – 2

How NOT to develop an overarching public-facing narrative.

On Monday I talked about the important idea of developing an increased skills mix in health and social care practice. I looked at how important it is to have conversations with staff who may not find it easy to change the way in which they work.

Today I want to start to discuss my second theme of change. The importance pf developing and using an overarching narrative for the change.

Today is mainly about what not to do in developing this narrative.

Tomorrow’s mainly about what to do.

But first,

Given the NHS’ ability to quickly forget things I’d like to remind everyone of a serious experience of such work in the past – about 15 years ago.

Between 2007-10 one of the main issues facing the NHS were local reconfigurations. These changes – usually in the way in which different hospitals configured their services – nearly always meant that one hospital would ‘lose’ a service. This would lead to a powerful reaction against the change. Angry MPs in parliament, the local council up in arms and people marching on the streets.. Many of these configuration battles went on for more than a decade and usually at the end decisions were taken on the force of public opinion. (Not itself a bad thing!)

I remember local doctors who had argued that these changes were very much in the public interest being completely puzzled at the extent of public opposition. They were furious that something that they firmly believed would save lives was being dismissed by ‘bureaucrats’.

Of course it wasn’t actually bureaucrats but the public using their voice. It struck me at the time (and it’s important in the context of the overall argument in this post) that we give the public very little voice in the NHS. But they claimed that right with reconfigurations and they can – and do – say NO. (Given that it’s their only chance to have a voice – let’s not be too surprised when they use it.)

These reconfigurations went on for a long time. Until somewhere near the top of the NHS (Before the current days of NHSE) someone came up with the idea that before any NHS locality was allowed to begin a reconfiguration, they had to develop something called ‘a compelling case for change’.

I remember this phrase because it became, as with so many projects in a large organisation, a phrase which people used without really listening to the words. Just having one meant permission to continue with their reconfiguration programme. So, since they had to, everyone developed their ‘compelling case for change’ before they were allowed to launch their reconfiguration.

A couple of years into this process I started to work for myself as a management consultant. In the next year or so I went to several parts of the country where they had launched reconfigurations and on many occasions people would start the conversation with “The trouble is no-one agrees with our ‘compelling case for change.’

(There are times in life when you are certain you are in a comedy sketch.)

Obviously, the problem here is that internally you can call something whatever you want. You can even call a case for change compelling when it isn’t – but if it doesn’t compel anyone, it’s pretty meaningless.

This historical detour leads us to the first and most important rule in constructing a public-facing narrative for change in the NHS.

If you’re going to persuade the public, it’s very necessary to talk to them before you finalise your overarching public-facing narrative. The reason people leading change don’t do this is not because they are bad people, but because it makes the process harder. It makes it a lot harder. Sitting in a room and writing a ‘compelling case of change’ is hard enough but going out and talking to the public about it means you lose complete control of it.

The trouble with the public is that they just don’t think like you. They think like they do, and  worse still, they always think in different ways from each other. So, whilst sitting in a room and getting agreement from NHS staff about the compelling case for change has its difficulties, leaving that room and going out to discuss the issue with the public is really tough.

And returning to the biggest of big pictures, since we tend to go on about the NHS ‘belonging to the public’, it kind of means we have no choice. If we don’t engage with them about what it means for them to move into the process of change, they will say NO and your change will be stopped in its tracks.

Returning to the public-facing narrative for a greater skills mix, when you put it like that, very few people are interested. So, the first issue to consider before involving the public in your narrative is think about how this change impacts on them rather than just talking about internal NHS change.

If the sole point of a greater skills mix is internal – you will not win the debate about change with the public. Because one of the main points about this process is whilst you are developing your public-facing narrative for change, those that will resist it are developing theirs.

There will be a row between competing narratives. Your one for change will not be the only one. The one against change will be there competing with yours. If you are not good at what you do – you will lose.

In this example those opposed to change will say that what this greater skills mix meanss is that you won’t get to see a doctor. And thst if you don’t get to see a doctor and a non-medic sees you, they may make a mistake and you may die. We have seen narratives develop this way in the recent argument about Physician and Anaesthetic Associates.

Therefore, when you are organising for change ALWAYS expect opponents to mobilise public-facing arguments against you. ALWAYS expect that they will contain frightening threats about the impact of the change for which you are organising. If you don’t recognise that you have to counter these arguments you will lose the public

It’s rough out there.

And if you don’t engage you will not get your change through.

In our example today, a greater skills mix has to demonstrate to the public how it provides them with a better service than exists at the moment.

That may seem very obvious, but in public services it’s difficult – for one very big reason. If we explore the failure of the present, then we have to say something is wrong with the present service that we are going to improve.

But the NHS who are organising the public-facing narrative for the future are linked to the people who have been delivering the present service. So the former have to develop a critique of their mates because they are delivering the service that they need to criticise.

For me it is this problem that has limited much successful reform in the last few years.

This doesn’t happen so much in the private sector as those organising the change are often in different organisations. They are in new, disruptive companies and it’s fine for them to criticise present practices because they are not delivering them. Being new and better in the private sector allows you to criticise incumbents.

The public-facing narrative for a better skills mix will be made by one part of the NHS criticising another. If you are not prepared to do this – skip the next few weeks of blogs because you can’t be serious about change. If your narrative for change says that present practice is really good why should the public support changing it?

So today’s takeaways are,

If you don’t involve the public, you will fail.

If you expect your narrative will not be contested by those defending the present, you wll fail. There will be a row.

If you don’t win that row, you will fail So win it.

If your narrative doesn’t critique the present, why should the public support the change?

Tomorrow we will explore how to develop the positives in your narrative for change.