A quiet revolution: Making the case for changes to the NHS

All three main party leaders put the NHS at the heart of their conference speeches this autumn. This was no coincidence – a recent poll revealed it to be to be the issue at the top of most voters’ mind when considering how they’ll vote next year, and the NHS remains unique amongst British institutions as an object of affection.

In recent years though a consensus has developed within much of the ‘health sector’. A stronger focus on providing care for people at home, through GP and community based health and care services, would both address many of the challenges the NHS and social care systems in the UK currently face, and also lead to better outcomes for patients and service users. There is also agreement that greater investment is needed as demands rise, especially from an ageing population.

However, the public fiercely resists change, especially if it entails closing a much loved local hospital, resulting in a stasis within an increasingly risk averse political establishment. Against this backdrop, members of the Richmond Group of health charities commissioned BritainThinks to conduct qualitative research to understand how best to make the case for change.

We ran focus groups representing a spread of socio-economic groups exploring spontaneous views on the health and social care systems. We also tested alternative expressions of the case for change. Our research revealed how much the public’s views differ from the health community on this topic. Understanding this is crucial for anyone wishing to bring the public on-side with change in the NHS.

The first key difference is that people do not perceive a ‘crisis’ in the NHS. In the early 2000’s, ahead of Gordon Brown’s national insurance rise, it was widely believed that the NHS was on the brink of total and irreversible collapse. Today, whilst experience of healthcare services and anecdotal evidence clearly suggests that the NHS is under strain, the problems the public see are not identified as symptoms of systemic failure. Talk therefore of a ‘crisis’ and the subsequent need for ‘urgent change’ in the system often fails to either engage or convince.

Secondly, unlike those in the health sector, the general public lacks interest in the system or the processes that underlie service delivery. Instead they are preoccupied with what the NHS is able to deliver to them personally. We asked participants to draw their own diagram of ‘the healthcare system’. The result was a simple, ‘me-centred’ perception of the NHS, showing a patient’s journey from doctor or hospital, through treatment to aftercare.

Thirdly, the public’s views on the types of pressure that the NHS is under are a further point of departure with the health community. Any appreciation of the rising cost of health and social care is largely absent. Rather, there is a deeply ingrained belief that all of the problems in the NHS can be attributed to two things: endemic waste and inefficiency; and large numbers of people currently ‘taking’ from the system who have not contributed to it.

Finally, when presented with alternatives for service delivery, people, while broadly accepting of arguments like prevention not cure, saw the propositions as common sense solutions rather than examples of innovative or radical change. Even the groundbreaking reconfiguration of stroke services in London was seen solely as an exercise in improving efficiency in the system.

This research has four clear implications for how politicians should talk about the NHS to make a compelling case for change. Any successful narrative should position such change, first, as evolution not revolution, rather than a radical change that is in response to a crisis. Second, it should be an opportunity to improve services for patients, rather than as primarily a cost-saving exercise. Third, it must be seen as a ‘common sense’ response, rather than an ideological vision. And fourth, change should be understood as a response to a growing ageing population and increase in long term conditions.

It will also be vital to avoid creating the sense that ‘change’ means a reduction in the provision of NHS services. The general public are particularly sensitive to losing the NHS touch-points that they see as vital to their accessing the service: GP surgeries and A&E departments. As Caroline Abrahams, Age UK Charity Director, who commissioned the research on behalf of the Richmond Group said, “the angst among policymakers about how to communicate the need for change in the NHS largely misses the point – the public expects the NHS to evolve in response to changing needs and will support you getting on with it. But clearly, you close the local A and E at your peril! It seems however that you can change much else that happens behind the hospital front door without undue public alarm.”

This work is just a start – there is much more to be done – for example, gaining a better understanding of how best to communicate community-based care – but it highlights the gulf in perceptions held by the health community and by the general public. Only by really understanding where the public are, and reflecting this in communications, can we hope to take them with us as we make the case for change.

Lucy Bush is an associate director at BritainThinks, and Deborah Mattinson is founder director of BritainThinks

This piece originally appeared in the Winter edition of the Fabian Review