On September 28, 2020, the local Clinical Commissioning Groups, collaborating with University Hospitals of Leicester NHS Trust, began a public consultation on plans to reorganise hospital services in Leicester, Leicestershire, and Rutland. The public consultation was called Building Better Hospitals For the Future (BBHFF) and ended on December 21.
Costing over £450million, the plans involve a significant amount of investment – part of the government’s key 2019 general election pledge to build new 40 new hospitals across the country. However, far from building new hospitals, the local Trust’s plans involve, amongst other things, the closure of Leicester General Hospital as an acute hospital, with acute services then concentrated on the city’s two remaining hospitals sites, and the closure of St Mary’s Birth Centre in Melton Mowbray.
The consultation took place while residents in Leicester, Leicestershire and Rutland were under various forms of restriction, including severe restrictions in November as part of the national lockdown because of the Covid-19 pandemic. Elsewhere, for example in Chorley, Lancashire, consultations were postponed but NHS leaders in Leicester, Leicestershire and Rutland decided to hold the consultation despite the difficulties this would involve for many members of the public. As a result, the process was driven online and all consultation meetings, which in normal times would be held in person, were forced to take place remotely.
What follows is a summary of some of the problems that beset the consultation and contributed to what we strongly feel was an inadequate consultation process.
Failure to deliver the consultation document
An early promise in the consultation campaign was that a brochure would be delivered to every door in LLR explaining the proposals, explaining how people could find out more, and asking for feedback on the plans. Unfortunately, however, this document appears not to have ever been received by a large proportion of households, possibly the majority of households. Whenever we asked people in meetings or on social media if they had received the leaflet, the vast majority said ‘no’.
Problems with the distribution of the brochures was acknowledged by the Chief Executive of the joint Clinical Commissioning Groups, Andy Williams, at a Joint Health Overview Scrutiny Committee meeting on October 15, and he stated that this would be looked into. However, an attempt to rectify this through another delivery appeared to work just as badly.
Local NHS leaders subsequently attempted to play down the importance of this specific form of communication with the public, but we ask why, if it was so unimportant, was it so central to their original plans and why did they spend so much money in sending the document, twice, to more than 400,000 homes?
Sending brochures to every home in the region seems like a very good way of addressing the problem of digital exclusion (something we come to later on), where people have no access to the internet or cannot access the internet with confidence. However, after two failed attempts to distribute the document, local NHS bosses gave up on this as a means of engaging the public.
A concern rising from this is that there may be significant portion of the population in LLR who were simply not aware that a consultation was taking place. https://www.facebook.com/SONHSLeicester/photos/948360335571374 This is something that was likely compounded by the effect of the pandemic, with deaths dominating the headlines, and people fearful for the safety of themselves and those around them.
While online consultation can increase the numbers responding to a consultation, many members of the public do not have access to the internet or cannot use the internet with confidence. In fact, many of the people who will be most affected by the proposed changes, including elderly or infirm people, people with mental health problems or with learning disabilities (who are more likely to require acute care than those without these conditions), as well as those struggling financially, are the least likely to be able to engage in an online consultation. In normal times, some of these issues can to a limited degree be overcome through access to technology, and support, provided at libraries and community centres. However, because of the Covid-19 pandemic and the closure of all non-essential services, this was not available. According to the Office for National Statistics, in 2018 there were still 5.2million adults in the UK who have either never used the internet or have not used it in the last three months, described as “internet non-users”. The 2019 Consumer Digital Index concluded 22% of the population) do not have the digital skills needed for everyday life in the UK. This means that as many as 1 in 5 people in LLR would not have had effective access to online meetings and other communications and sources of information. Anyone completing a hard copy of the questionnaire – which had to be specially requested – would have been completing it on the basis of only a tiny fraction of the information available.
This was a minor theme in a letter written to the Mercury by an elderly member of the public who described the prospect of engaging online as “daunting”. https://www.facebook.com/SONHSLeicester/photos/928955367511871
The trust claims to have received more than “90,000 unique visitors” to their website over the duration of the consultation. Setting aside whether this means 90,000 different people – which is highly unlikely – this number has been used in Scrutiny Committee meetings as evidence that engagement has actually been higher than usual, owing to paid adverts on a wide variety of social media platforms. Of course, not everyone uses social media, so it is unlikely to have reached those people. We also question the level of genuine engagement achieved by saturating social media with endless adverts.
Technical problems with online meetings/workshops and the online consultation document
Throughout the consultation, NHS leaders held a significant number of online meetings, hosted on Microsoft Teams, as a means of engaging the public. However, quite apart from the the fact that this could not be accessed by the digitally excluded, the platform sometimes proved inaccessible even for confident internet users for a range of reasons – a persistent theme in letters sent to the Leicester Mercury throughout the consultation period. Issues raised included:
- Multiple members of the public unable to access several online meetings because, after registration, they had not receiving the promised link to access the meeting. When a complaint about this was raised with the CCG, the explanation given was that they were facing technical difficulties sending and receiving emails, but to be reassured that the problems were now resolved. The complainant was asked to register for another subsequent online meeting. However, they faced exactly the same problems as before and were unable to attend (emails are available to support this). https://www.facebook.com/SONHSLeicester/photos/959266727814068 Another member of the public claimed that they had emailed the CCG three times requesting a link for a planned meeting, but to no avail. https://www.facebook.com/SONHSLeicester/photos/948353758905365
- A third member of the public who described himself as “computer literate” wrote to the Mercury to explain how he could not access a meeting, even after being sent the link. https://www.facebook.com/SONHSLeicester/photos/935391630201578
Technical problems were also noted with the online consultation questionnaire. Concerns were raised about the length of the consultation document and that if you took a break from filling it in, even for a short period, the document would reset, losing all recorded answers. For many people, even those who are extremely IT-literate, the document could have taken many hours to fill in, especially if the individual wanted to record answers in their own words in addition to rating from 1 to 5 how much they agree/disagree with a proposal. One couple who were in touch with our campaign explained how between them they spent more than ten hours filling in the consultation because of the problems outlined above. How many people would have given up after trying and failing to record their views? Poor internet connectivity with demand surging due to online learning, amongst other things, could also have been an obstacle to engagement. https://www.leicestermercury.co.uk/news/uk-world-news/poor-internet-connection-huge-lockdown-4094615
Because local NHS bosses failed to distribute the consultation documents, including the questionnaire, to every door in LLR, we anticipate that despite television and newspaper adverts, many people would not have known there was an option for requesting a hard copy questionnaire and would have been left successfully or unsuccessfully struggling with the online questionnaire. Indeed, out of population of 1.1 million, only around 570 people gave any offline response and just 103 people used the telephone option to complete the whole survey.
These are obviously just a handful of examples of the types of problems people faced in engaging with the consultation process, but we ask how many others have similar experiences of being shut-out due to “technical problems”?
Format of consultation meetings
Normally consultations would involve meeting publicly, providing an opportunity for the public to question NHS bosses and discuss with each other the proposed changes, including with those who may disagree with the narrative being promoted by NHS management. However, this was not possible due to the pandemic. Forced online, interaction between attendees was practically impossible, except for times when chat boxes were permitted. As many know from recent and ongoing experience, both personal and professional, ‘online’ is often only a pale substitute for the real world. We think that a healthy consultation is as much about the people discussing with each other as it is about discussing with NHS leaders. http://saveournhsleicestershire.org/2020/11/15/leicester-nhs-bosses-disappointed-after-bizarre-offer-to-takeover-campaign-meeting-refused/ However, the decision to hold the consultation in the midst of a pandemic made face to face discussion amongst members of the public virtually impossible.
Questions not being answered at Joint Health Overview Scrutiny Committee meeting
On December 14, the Leicestershire, Leicester and Rutland Joint Health Overview and Scrutiny Committee (JHOSC), the democratically elected body responsible for scrutinising the plans, with powers to make recommendations to NHS leaders, met to discuss and raise concerns about the Trust’s plans to reorganise hospital services. A video of the meeting can be found here. These meetings are open to the public with the latter able to submit questions beforehand and ask follow-up (‘supplementary’) questions at the meeting itself. A total of 26 questions had been pre-submitted, to which a written response from the NHS was supplied ahead of the JHOSC meeting, with eleven supplementary questions raised at the meeting itself. The chair of the meeting, Councillor Kevin Feltham, grouped the questions into four themes.
After roughly two hours, the chair drew this section of the meeting to a close. However, the response in the comments section of the meeting indicated that some members of the public felt that their questions had not been answered – a claim borne out in listening to the recording of the meeting. This concern was raised again after more than three hours into the meeting, at which point the chair pointed out that the relevant NHS spokespeople were no longer in the meeting – something of which members of the public, patiently waiting for answers to their questions, were not aware. At least two written complaints were subsequently issued to the JHOSC regarding this oversight from the chair. A response to these complaints was sent by the clerk to the committee. It reads:
“I am sorry that many of you have still not received written answers to the supplementary questions asked at the Joint HOSC meeting on 14 December. I have been regularly chasing the CCG for the information to help the Chairman answer these questions but unfortunately the CCG has been very busy with the Covid-19 vaccination programme and have not yet given me the information. This week I have escalated the matter with Andy Williams, CEO, LLR CCGs and he has promised I will receive the answers soon.”
In fact, responses to the unanswered supplementary questions were only provided more than five weeks after the close of the consultation! Of course, we understand completely that the CCG is extremely busy with the vaccination programme, which must remain a priority at this time, but it is precisely because there is a pandemic, with NHS leaders’ minds – and public minds – understandably focused elsewhere, that we feel that consultation should not have taken place. In fact, we do not understand why the chair of the joint scrutiny committee left it so late in the consultation period before holding this meeting. The level of public interest in controversial proposals, entailing the closure of a major hospital and a birth centre, could have been anticipated and more effective plans for scrutiny put in place, for example holding an additional meeting in November and not leaving the final meeting until so close to the consultation deadline.
In addition to questions going unanswered, there is also a question about the competence of the JHOSC chair and whether or not his role was adequately carried out. To understand this, it is worth considering the purpose of scrutiny. According to government guidelines: “Scrutiny has a legitimate role in pro actively seeking information about the performance of local health services, challenging information provided by commissioners and providers of services for health service and in testing this information by drawing on different sources of intelligence.” [Our italics]. However, throughout the meeting we gained the impression the chair was sometimes using his position to block fuller scrutiny of the plans. At one point, in response to criticisms of the Trust’s plans, the chair intervened to explain that “I have said to a number of people over the past few weeks, this is £450million worth of reconfiguration investment, with huge potential for the area, and it’s a shame really that many people are concentrating on certain aspects, it’s a shame” (2:01:22).
Following a complaint about the conduct of the JHOSC chair, Councillor Feltham responded with the following:
“Chairing meetings of Council Committee is difficult at the best of times and is particularly challenging when politically contentious matters are being debated and the whole process is done remotely. As Chairman I need to balance the need for a robust debate whilst ensuring that the meeting is conducted in an orderly manner. I believe that in this instance that the meeting was managed appropriately. As this was a consultation regarding an NHS proposal it would have been open to all those who had submitted questions to respond or submit questions directly to the CCG and UHL on particular issues of concern to them.”
We are pleased the chair acknowledges the contentious nature of the proposals. Had he not left this meeting to the final week of the consultation process, there would have been adequate time to ensure that questions from the public were answered before the consultation deadline.
Outstanding supplementary questions from the JHOSC on December 15 were still unanswered by NHS leaders as late as February 26, after a further request for clarification was raised on February 24. As the clerk to the committee stated on February 26:
“I’m afraid I cannot give you a precise response for when the answers will be received. I have been regularly chasing the CCG for the information but not received the information yet. I emailed the CCG yesterday and was told they would call me today but so far nobody has called me. If we don’t receive anything by next week, I am sure the Committee members will raise the issue with the CCG during the public meeting.”
Further concerns about the competence of the JHOSC chair were raised after answers to the supplementary questions were finally provided on March 1. On March 7, a member of the public wrote to the clerk of the committee to express disappointment that it had taken so long to receive an answer, and to point out that the answer provided by NHS leaders did not in fact answer her question at all.
Public representation to the JHOSC dismissed
The first meeting of the JHOSC to coincide with the consultation was held on October 15. Roughly 20 members of the public had put their signature to a representation to the meeting in order that their concerns about the plans might be heard. However, despite receiving assurances prior to the meeting that the representation would be heard, this was dismissed out of hand by the JHOSC chair, Councillor Feltham: “Item 9 building better hospitals for the future: I said earlier, we received a representation on behalf of twenty members of the public, although I am not taking that on board as it came too late, but if members wish to read it and take up the points they raised then by all means do.” (2:00:12) https://youtu.be/E0lRzvjdSy8?t=7212
Private briefing on beds following JHOSC
One persistent theme that came up throughout the consultation was the number of beds being proposed in the Trust’s plans. With a growing and ageing population Leicester, Leicestershire and Rutland, in addition to services that are regularly stretched to capacity, you might expect that expensive plans to reorganise hospital services would involve a significant increase in the number of beds available. However, local NHS leaders want to pursue a different approach to treatment, where many patients, particularly elderly patients, are treated in the community rather than in hospitals. This, they say, will ease the capacity problems in hospitals, freeing up beds for those who really need them. Campaigners and members of the public, on the other hand, question where the funding is coming from to ensure that care in community, which itself is already in crisis because of a decade of austerity, is able to cope with a huge surge in demand. This issue has come up several times at public meetings we have organised in recent years.
During the Joint Health Overview Scrutiny Commission meeting on 15th October, it was agreed that a separate briefing would be arranged with members who wanted a further conversation on points relating to bed numbers in the proposed plans. Two members of the public received invitations to this important meeting; however, later on they received notification that this meeting had been cancelled. But as later came to light, the meeting had not in fact been cancelled for the councillors. This was supposed to be a ‘public’ consultation. It is precisely on the question of bed numbers that the public had the most questions of the Trust, making it even more important that all discussion on the subject is held in the public.
Media coverage (or lack thereof) and misleading headlines
One obstacle to real public engagement throughout this consultation was the lack of interest apparently shown by sections of the local media. On the face of it, this is surprising. £450million is a huge amount of public money and it is unlikely that we will see similar capital investment for decades to come. The implications of the proposed changes are extremely far-reaching with the local NHS Trust planning to change the way that care is provided into the future, with far greater emphasis on care in the community than on traditional models of care.
Of course, there are concrete reasons why the consultation might have received less coverage: health reports in the local press were overwhelmingly dominated by news around the pandemic and its impact on local hospital and primary care services – something which campaigners frequently pointed to as a reason for postponing the consultation; it is also true that lockdown prevented public protests and demonstrations taking place which would normally attract media attention. However, you might have expected these factors to be offset by the impact on questions of public health and future pandemic preparedness which were foremost in the consultation. Yet there was little engagement from NHS leaders with public concerns about pandemic preparedness (for example the plans suggest intensive use of estate when handling a pandemic requires feasibility in the use of estate) other than to repeat that the proposed hospital arrangements would enable a better response to a pandemic than the current arrangements.
In some ways this reflects the lack of coverage received by campaigners – if the concerns of campaigners and public are not receiving media coverage, scrutiny of NHS responses to these concerns is reduced. On the day the consultation began (September 29), campaign officers from Save Our NHS Leicestershire were interviewed on BBC Radio Leicester and briefly on BBC East Midlands. Our objections were also covered online and in a front-page report in the Leicester Mercury on October 20. However, the headline misleadingly gave the impression we opposed £450m investment. The Mercury also organised online interviews with NHS leaders about their plans, livestreamed on Facebook, but without the balance which would have been provided by interviewing campaigners as well.
And this was not for any lack of public interest on the matter. On the contrary, the unusually high number of letters sent into the Leicester Mercury letters page during the consultation (in excess of 30 over a twelve-week period – roughly one every three days), submitted by campaigners, other members of the public, and once by local NHS bosses, suggests an extremely high degree of public interest in the consultation. But this was not reflected in general reporting in the local press, the Mercury and elsewhere.