Communications and engagement in health and social care: A cautionary tale from Cornwall

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Executive summary
This report demonstrates why, in the field of health and social care, responsibility for communications and engagement should not be combined in a single position. It tells the story of Cornwall’s Sustainability and Transformation Plan from late 2016 to mid-2017, focusing on the problems of securing ‘engagement’ by the public. It reveals how communications between health bodies and the local authority, Cornwall Council, have come close to breaking down, and identifies the root cause of this as the combining of responsibilities for communications and engagement in a single position.

Communication: necessary but difficult
Under the terms of the Cornwall devolution deal, the organizations responsible for health and social care in the Duchy are supposed to be getting together to produce supposed to be getting together to produce a business plan for the integration of health and social care services. Health care is the responsibility of NHS Kernow (the clinical commissioning group), a number of ‘provider’ Trusts, and independent GP practices, while social care is the responsibility of Cornwall Council, the local authority, with its elected members and salaried officers. The ‘third sector’, made up of charities and voluntary bodies, also plays a significant part in both health and social care.

With such a wide range of people involved, from a wide variety of types of organization, it is crucial that they communicate with one another. Communication is not easy. There are always obstacles to be overcome – lack of trust, differences in rank, organizational loyalties pulling in different directions, people covering their own backs, professional rivalries, different views of what is important, competition for funds, and so on. So to communicate effectively everyone has to make an effort. And just one person can foul everything up.

The STP survey
Recent work on the integrated care plan for Cornwall – it used to be known as the ‘Sustainability and Transformation Plan'(STP) but has now been rebranded as the ‘Shaping our Future’ plan (SoF) – reveals the problem.

Over the winter of 2016-17 a questionnaire-based survey was carried out in Cornwall. Its wording was widely criticized. The questionnaire elicited responses from 1896 people (fewer than 1 in 250 from Cornwall’s total population of more than half a million). I learned four weeks ago, by accident, that a team based at the University of Exeter had examined the data collected and produced two reports: a summary report and a detailed analysis. These reports, which can be read here and here, have never before been placed in the public domain.

We learn from the University of Exeter reports that while 1896 people completed the survey, around 30% of them – i.e. around 570 – were a ‘health and care professional or support worker’. So only 1330 or so were ‘lay’ respondents, members of the general public. Moreover, among the 1896 there were no fewer than 762 references (around 40% of all respondents) to ‘needing more information’ and 352 references (around 18% of all respondents) to ‘not understanding the question’.

Further analysis of the data will show whether the 570 health and care staff had difficulty with the questions: if in the main they did not, it could follow that as many as 50% of lay respondents felt they needed more information and as many as 25% of them did not understand the question. These are not insignificant proportions.

In their summary report (p.16) the University of Exeter authors noted that the consequence of many participants needing more information and not understanding the question is that ‘caution should be taken in drawing firm conclusions from the data. Specifically with regard to inferring that a high level of ‘agreement with priorities’ translates to an overall participant endorsement of the STP’.

The involvement of Cornwall councillors
Cornwall Council has a Health and Adult Social Care Overview and Scrutiny Committee (HASCOSC). It set up an STP sub-committee which took a close interest in the STP survey. It held several information-gathering sessions, with the final one on March 10th, 2017.

The University of Exeter summary report is dated March 3rd, 2017, i.e. a week before the final STP sub-committee’s final information-gathering session. (The team’s detailed analysis is dated March 30th, but a version was presumably available by March 3rd or it would not have been possible to summarize it.) However, the summary report was not shown to the sub-committee.

Following its meeting on March 10th, the STP sub-committee went on to submit a position statement to HASCOSC, in which it concluded, among other things, that ‘the process of engagement with the public was inadequate and seriously flawed [and that] the questionnaire contained closed questions, was ill conceived and was unprofessional’. They were ‘disappointed that the report from the engagement events was not available when they were considering this issue’. ‘The engagement process was poor and ill-judged.’

HASCOSC met on March 15th. The Committee had in front of it the STP sub-committee’s position statement and an update report from the SoF Communications and Engagement Lead, Garth Davies (who is also Associate Director of Communications and Engagement at the Royal Cornwall Hospital Trust). Tabled at the meeting was Mr Davies’s own report on the ‘engagement activity’. He was asked if advice had been sought on the structure and nature of the questionnaire. The minutes of that meeting tell us that he ‘confirmed that advice was taken from the University of Exeter’. Later on March 15th I emailed Dr Michael Leyshon of the University of Exeter team and asked him: ‘Were you involved in designing the survey questionnaire?’ He replied the following day: ‘The simple answer to your question is no.’

So Mr Davies had withheld the University of Exeter reports and instead written and published his own views on the ‘engagement activity’. His report included (p.5) the following statement:

Overall, it is clear that respondents supported the priorities and case for change set out in the Shaping Our Future documents with many saying it is hard to disagree with the positive approach. Respondents said the top priorities should be ‘Prevention and improving population health’ and ‘Integrated care in the community’.

As we see, he effectively disregarded the academics’ warning against inferring that a high level of ‘agreement with priorities’ translates to an overall participant endorsement of the STP.

It is relevant here to note that both of the University of Exeter reports carry the statement: ‘This report has been produced for the sole use of the NHS Communications team, namely Garth Davies, in order to write the STP Engagement Report. The report is not for circulation nor use by any other party.’ Given that the reports draw on responses from the public and have been paid for with public funds, that prohibition is clearly wholly unmerited.

Interestingly, while the summary report reveals that among the 1896 responses to the STP survey there were 762 references to ‘needing more information’ and 352 references to ‘not understanding the question’, these figures do not appear in the detailed report: evidently some editing to remove embarrassing findings took place between March 3rd and March 30th.

In an email to a colleague on April 24th, Mr Davies wrote: ‘I will publish the analysis reports and survey summary report on the website.’ Assuming that the website to which he referred is, by 11th July 2017, more than 11 weeks later, the reports had still not appeared.

On March 17th, the SoF Transformation Board (see below) met. The chair, Kathy Byrne, is recorded in the minutes as saying that the STP sub-committee’s position statement ‘was not particularly helpful for public confidence and noted that the framing of [it] has made the job harder’. She also ‘noted the importance of working more closely in the future’.

Members of Cornwall’s public might perhaps share my view that withholding information from councillors and misrepresenting survey findings – and continuing to do so – does the very opposite of inspiring me with confidence, nor can I see how it might contribute to ‘working more closely’.

The engagement report: what it tells us and what it doesn’t
I noted above that while 1896 people completed the survey, around 30% of them – i.e. around 570 – were a ‘health and care professional or support worker’. So only 1330 or so were ‘lay’ respondents, members of the general public. The engagement report tells us more. Of the 1896, 1258 were of working age (19-65). These working-age respondents will have included nearly if not all of the health and care professionals/support workers. So that group will have contributed around 570 to the 1258 working-age respondents. In other words, nearly half of the working-age respondents (45%) were health and care professionals or support workers.

People employed in health and social care amounted to around 13% of the working-age population of Cornwall in 2011. So they were considerably over-represented among respondents to the survey. By no stretch of the imagination, then, can the survey be said to have been a survey of a representative sample of the general public.

Unfortunately the engagement report does not distinguish between the responses of lay people and health/care workers. It lumps everyone together as ‘respondents’ or ‘people’. So when Mr Davies concludes in his engagement report ‘Overall, it is clear that respondents supported the priorities and case for change set out in the Shaping Our Future documents with many saying it is hard to disagree with the positive approach’ we have no idea of how far these results could have been skewed by the over-representation of health/care workers. And if we look at how those priorities were set out in the survey, we see that they mostly took the form of ‘motherhood and apple pie’ aspirations, inherently impossible to argue against.

And here’s another thing. If you look at the pie chart below, which shows the six priorities offered in the STP questionnaire, you will see that another priority, ‘Transforming urgent and emergency care’, tied for second place (at 19%) with ‘Integrated care in the community’.

Evidently Mr Davies chose to include ‘Prevention and improving population health’, along with ‘Integrated care in the community’, as top priorities, but to exclude ‘Transforming urgent and emergency care’ although it came equal second in the ratings. This ‘cherry picking’ is not an acceptable way of presenting the results of a survey. And it leads us to ask what else has been cherry picked to go in the engagement report.

When we read on, we learn that ‘The main concerns people identified were:

Potential reduction in community hospitals with concerns about travel times and the impact on the major hospitals without alternatives yet in place.

Financial with people wanting to see more investment in community services and many questioning whether the plans could be delivered within the budget.

Workforce with people wanting to see more investment in community staff and training.’

It is hard to match these up with the ‘top priorities’. And the second and third of these concerns could well reflect the over-representation of health/care workers among respondents.

The use of impressionistic language in the engagement report – ‘Many people commented …’, ‘Many said …’, ‘People wanted …’, ‘Others thought …’, ‘People felt …’, ‘Many respondents said …’,‘An overwhelming majority of people agreed …’ – and the withholding of actual numbers (we are never told how many is ‘many’) means that we have to depend on the author’s predilections and judgment. The language used and the instance of cherry picking from the pie chart must raise doubts as to the reliability of everything the engagement report says.

Recent developments: (1) The Transformation Board
Ideally one would want to see the unfortunate STP survey and engagement report consigned to history. Is this happening? Seemingly not.

Work on the ‘Shaping our Future’ plan is now being overseen by a Transformation Board, which is chaired by Kathy Byrne, who is also Chief Executive of the Royal Cornwall Hospital Trust. Its membership includes some officers and elected members of Cornwall Council, as well as numerous ‘system leaders’ from health provider bodies. (Members’ names and affiliations and the minutes of its meetings can be seen here.)

Ms Byrne submitted a report on Shaping our Future for the meeting of HASCOSC on July 12th, 2017. It includes a section on ‘Consultation and Engagement’ which reads as follows:

Between November 2016 and February 2017, local people were asked to give their views on the Shaping Our Future outline proposals through a survey, written responses or by attending a series of community and stakeholder events.

Over 5000 local people responded or took part in the events and said top priorities should be ‘Prevention and improving population health’ and ‘Integrated care in the community’.

As we can see, this is simply talking up the numbers and parroting the engagement report. As in that report, ‘Transforming urgent and emergency care’ does not appear as a top priority despite tying in the ratings with ‘Integrated care in the community’. What are we to conclude? It appears that Ms Byrne has rubber-stamped the engagement report, rather than subjecting it to careful and critical examination.

Sadly, we may expect similar behaviour from other members of the Transformation Board. Having been set up as a ‘stakeholder body’, its members are likely to read documents that come their way solely with a view seeing how the interests of the body that they represent could be affected. 

It follows that there is a great need for members of Cornwall Council’s Overview and Scrutiny Committee to bring their knowledge and critical faculties to bear and do some thorough scrutinizing. They should have investigative staff to help them in this: it is not a job for the secretariat that normally supports council committees. Ideally such staff should be able to link to voluntary and campaigning bodies, since many of these have good local knowledge and grasp of the policy process. 

Recent developments: (2) Working with people from local communities
In her report to Cornwall Council’s Health and Adult Social Care Overview and Scrutiny Committee on July 12th, Ms Byrne noted: ‘Two engagement experts have been secured from NHS England and the South West Commissioning Support Unit to help shape our engagement programme.’ One of these, Dr Lou Farbus, is now running a series of ‘co-production’ workshops across Cornwall and the Isles of Scilly, in which people who have recently received or who care for someone who has recently received some kind of health or social care support can meet people who are involved in delivering a service, to exchange views and perspectives and explore possible ways forward. Having myself taken part in one such workshop, I can vouch for their effectiveness in broadening one’s mind, in helping one to appreciate the work that other people do and the issues that they face, and in stimulating constructive, ‘out of the box’ thinking.

A fatal flaw in the NHS
A common feature of NHS bodies is that they bundle together responsibilities for communications and engagement. These are fundamentally different activities. Communications experts, who in many cases have had a training in journalism, are trained to use the media, to ‘put the message out’ and put a positive gloss on it, even to ‘spin’. In contrast, successful engagement involves dialogue, two-way communication: it requires skills in listening, in appreciating what others are saying, in responding appropriately, gaining other people’s confidence, being open and ‘straight’ with them, and able to negotiate compromises. These are two different skillsets.

The experience of the STP in Cornwall constitutes just a single case study, but it shows what can happen, and did happen in a particular situation. It has highlighted the differences between communications and engagement, and there are indications that these may cause problems elsewhere, not just in Cornwall. So perhaps the main lesson to draw from the experience of the STP in Cornwall is this: Do not combine responsibilities for communications and engagement in a single position. And indeed, beware the communications expert who fancies himself (or herself) to be an expert in engagement too.

Peter Levin