Changing the NHS – The need for a new Skills Mix – 3

Successfully developing an overarching public-facing narrative.

Yesterday I explored some of the pitfalls and traps you should avoid when creating an overarching narrative forchange within the NHS.

Today I’m going to look at some of the positives that can be deployed in the battle for change. But first I want  to reiterate one of my key points.

ALWAYS be prepared for strong counter narratives defending the status quo.

Don’t be surprised at the unfairness of this. You will have to justify in great detail all aspects of your proposed change, but the status quo is just that, and doesn’t need to justify why things are the way they are.

You will need to be robust in your arguments and, however persuasive, don’t expect the forces defending the status quo to give up after your first exchanges  – they won’t. The row will go on and on, and only if you are prepared to go on and on (and on and on) will you and your innovation for skills mix win.

In the next decade, when compiling your narrative for change for a new skills mix, you will probably have the advantage of examples where what you want to bring about is already happening.

There are thousands of small but important innovations in the NHS which stay at a small scale. It is very likely that what you want to create will be already happening somewhere. Don’t ignore this. (Remember Machiavelli’s dictum that the future you want to create will, when it comes to pass, find those who gained by it, arguing for it. But before that happy outcome there will only be a few self-interested people to argue for the change. That’s true at the level of powerful advocates BUT there will also be people who have worked with different skills mixes who will advocate for it. And, importantly, members of the public who will have experienced it and liked it.

Think about the recent row about physician and anaesthetic associates. No-one garnered the good experiences that patients had had with these associates and put them front and centre in a narrative for change. To win change that needs to happen.

I recall working with GP practices where patients resisted being seen by a nurse because they thought the GP was the person they needed to see. But when they did spend 20 minutes with a nurse they felt it was better than their 7 minutes with a doctor. In arguing for a new future finding people who will testify to having actually had experience of your change and felt it was beneficial, will be an important part of the narrative. Ask them for their experiences, use their words and use them over and over again.

Secondly, find concrete public experiences of the problem you are trying to solve. If these suggest that people feel nothing is wrong with the status quo they will be puzzled as to why any change is needed. And, as I suggested yesterday criticising current NHS services is not easy for those NHS staff wanting change because it is their colleagues who currently provide the service you want to change. But this is absolutely necessary to bring about the change you want.

To take the example of the need for skills mix. In 2024 the public are waiting, sometimes a long time, for many clinical appointments. They really don’t like that. They are frightened.  They really want to see someone, and they would rather it were a clinician – but their anxiety about waiting generally means they want to see anyone. So a skills mix which will deliver that opportunity is a plus for them. And they would say so.

As far as current services are concerned, there needs to be empathy for the current harder working staff. There must be a recognition that, whilst it would be great to increase the number of clinicians working in this area, there aren’t any available.

“We have tried to get some more, we have scoured the world to get some more. There simply aren’t any.”

So we either condemn staff to being horribly overworked and the public waiting for a very long time, or we increase the number of staff we can employ by developing the skills mix. The argument can be presented along the lines of, “…as they have done in location x (see above), a patient there recommends it. He says ……)”

Thirdly, one of the important developments in recent years has been the way in which many specific disease charities have become advocates for the new. Historically, one of the main aims of theses charities has been to make the case for increased spending on “their” disease. (“My disease kills more people and therefore deserves more money”). Given each of their charitable purposes this is not at all surprising.

But in recent years we have seen a growing recognition that it’s not just MORE that matters but also DIFFERENT. Given the narrative you are creating is arguing for a different approach to skills mix, it is often the case that these charities will be in favour of the new.

To take one example amongst many. We know that many patients can reverse their diagnosis of Type 2 diabetes by going on a strict diet and exercise regime. Consequently diabetes’ charities have become interested in employing weight control nurses to hep diagnosed patients with their diet. They are in favour of a skills mix.

It’s also the case that a wide range of charities concerned with long-term conditions have recognised that social prescription can have an important role in self-maintenance for patients suffering from such conditions. Make sure you seek endorsements from these charities since they are now often fighting hard for new ways of working with different skills mixes.

Fourthly, having developed your public facing narrative, make sure it actually faces the public. Have a plan for getting the narrative out there. This is a lot easier than you think, especially if you have the example of this actually happening somewhere. And don’t necessarily try and get it into the national media.

I was struck during COVID lockdowns how often (several times a week) the regional BBC and ITV news carried examples of the new ways in which the NHS was working. There are other daytime TV programmes about half of which seem to be about health and health care.

These programmes need human stories every day. You have – if you’ve constructed your narrative well – a human story. Help deliver them from the terror of having too little to put on their shows by giving them something.

Lastly, I made the point yesterday that there will be a counter narrative defending the status quo and that you will have to combat that. Don’t think that that is ever in any sense’ done’. It takes a long time before those defending the status quo stop. Be prepared to lay out your public facing narrative again and again.

You will quickly get bored with saying the same words over and over. You will be convinced that everyone is as bored as you are and surely you can stop telling this boring narrative now because everyone has ‘got it’.

Not true. Victory for the new in the war of narratives will go to those that can argue the longest. After what to you seems ages, there will still be lots of people hearing tit for the very first time,

In 2001-5, when I was working with Alan Milburn and John Reid to persuade the NHS that long waits were very important, it took about18 months before any significant group agreed with the idea of targets. And the rest of the 5 years to run that argument throughout the NHS.

So be prepared for the long haul. It may feel boring to you but for some of those you talk to it will, even after several years, be new.