The art of national conversation – using deliberative engagement for the future of the NHS

Hailed as the ‘biggest national conversation about the future of the NHS since its birth’, Change NHS, the public engagement exercise launched by the government to inform a new 10-Year Health Plan, is nothing if not ambitious. One of its most eye-catching elements is a series of in-person deliberative events with the public and NHS staff.  

Deliberative engagement aims to put people at the heart of decision making. Participants weigh up options for responding to complex problems where there are no easy solutions, only trade-offs. This can help policymakers navigate difficult decisions, inform public participants on the issues and build public confidence in the policymaking process. 

Last year, the Health Foundation and Ipsos undertook extensive deliberative research into the public’s views on the future of the NHS in England, involving 71 participants in three 2-day workshops in different parts of the country. Here’s what we learned. 

Developing policy: what to deliberate with the public, and how? 

The ‘three big shifts’ that will be set out in the 10-Year Health Plan – moving more care from hospitals to communities, making better use of technology and focusing on prevention – look to be where deliberative engagement can have the biggest impact. But how best to proceed? 

Based on our experience, an early consideration should be how to frame the options to deliberate. Each ‘shift’ comprises competing priorities, different visions for how radical the government should be and numerous policy ideas. These need to be distilled into several distinct options participants can weigh up. 

Bringing the implications of each option to life will be another task, albeit one this ‘national conversation’ is well placed to do. The government can bring together diverse expertise and perspectives to inform discussions and use data and analysis to make different approaches feel tangible. 

But even deliberative engagement done well can lead to other challenges. If policymakers struggle with difficult decisions, participants may too. We found this when asking participants whether focus should be on improving primary care and community services or hospital services. While participants can ultimately be pushed to pick one side or another, understanding the factors that shaped their choices, the nuances of how their views changed and any reservations they expressed is as important as their final decision. 

Informing the public: will the national conversation manage expectations?  

Satisfaction with the NHS is at a record low. Following Lord Darzi’s diagnosis of the state of the NHS, ministers may be hoping Change NHS will help raise public awareness of why the health service is struggling and manage expectations of what the government can achieve in the short term.

Our research found the public has a relatively nuanced understanding of the poor state of the health service and how this has come about. Even so, hearing an evidence-based assessment of the challenges facing the NHS left many participants shocked and some angry. 

Nevertheless, participants appreciated having a frank overview and wanted greater transparency from government. A national conversation could help to forge a new social contract about the future of the NHS.

Building confidence: will the public have more faith in government plans as a result? 

We also explored what would build confidence in a future government’s plans for the NHS – including embedding more public engagement in decision making. There was broad support for such engagement, but participants had reservations about it being little more than a box-ticking exercise.

Showing how Change NHS has influenced the policymaking process will also be important. Are ministers ready to accommodate the outcomes of deliberations or account for why a different approach is being taken? Finally, while taking part in a deliberative process can leave participants feeling more engaged and informed, bringing the process to life for those not directly involved needs careful thought.

Public engagement alone may not be enough to build confidence in the government’s plans. In our research, participants liked the idea of a future government taking a longer term approach but also wanted less political involvement in NHS decision making. That led people to favour the NHS having greater independence from government – an idea that seems unlikely to find favour with ministers – or an independent commission/review to support long-term planning for the NHS. 

The government wants Change NHS to provide ‘unprecedented levels of transparency’ to the policymaking process. This is welcome, but ministers should not underestimate the challenges involved with doing this well. And, with high levels of distrust in government generally, showing how the national conversation has informed the 10-Year Health Plan for the better will be essential.