NHS Duty to Involve and Digital First Engagement

What if face-to-face patient and public involvement was no longer an option? How does digital first engagement relate to the most regulated field of public participation in the world?

When it comes to engagement, involvement or consultation the UK’s National Health Service is probably the most highly regulated sector in the world. Indeed, there are Acts of Parliament for NHS England alone, making patient and public involvement in health and social care a statutory obligation, with reams of official NHS guidance detailing how this should be done. Similar requirements are also placed on the NHS in Scotland, Wales, and Northern Ireland.  Typically, this means that commissioners of health services and providers (e.g. hospital trusts) must involve people in proposals for changes to their local health services. This takes the form of informing, involving and consulting, with many people getting confused over which one they are actually doing (but that’s another matter for discussion).

NHS and best practice engagement

NHS and best practice engagement

“The NHS is accountable to the public, communities and patients it serves.” NHS Constitution

Over the years, people working in communications and engagement in the NHS have become very good at delivering best practice patient and public engagement, as well as meeting their legal requirements for public consultation, as per the Gunning Principles. However, their approach has been, what we might now call, traditional. That is, using a mixture of face to face (stakeholder) workshops, focus groups, paper surveys and so forth.  Don’t get me wrong there have been some great examples of more deliberative engagement via stakeholder panels, Citizen Assemblies, World Cafes and the like. But again this has mainly been offline.

My question is how do commissioners and providers of NHS services meet the requirements of their general duty to involve in a digital-first world?

It might appear extreme for, of course, people will always want to attend face-to-face meetings. But what if the default position is digital first and the face-to-face aspects of patient and public involvement in health and social care planning are the minor ones? What does this mean for managers trying to involve people in their plans for changes to hospital, primary care or mental health services? What does it mean for people managing major changes who want to avoid successful claims for judicial review – on the grounds that the public consultation was flawed or unfair?

But a digital-first approach to the general duty to involve can – and will – help NHS managers to meet best practice, adhere to their own guidance and stick to legal principles like Gunning One, Two, Three and Four!

online participation

Can online participation rebuild faith in citizen engagement?

Before we reconsider the duty to involve for a digital-first world let’s take a brief look at the state of online participation. In a nutshell, over the last few years we have learned that online participation and in particular social media has:

  • Polarised debate and sent people down the route of binary choices when it comes to complex discussions (like health care)
  • Encouraged the propagation of online echo chambers where people only talk to like-minded people, to the detriment of public discourse and rational debate
  • Been manipulated by big tech algorithms and the power of micro-targeting (a.k.a Facebook advertising)
  • Helped to distribute fake news and allow people to dismiss expert views and facts at will, without intelligent consideration of the issues

All of the above has helped to reduce trust in government, the media, public bodies, politicians and organisations, like the NHS. As a consequence of this techie disruption to civic engagement many people now believe democracy and by association public participation is in crisis.

So when we talk about digital first and online participation in healthcare we must also have all of this in the back of our minds. We need to consider that we are also part of a wider process of rebuilding faith in citizen engagement. And this will require much more than an online survey!

Rethinking the general duty to involve for digital first

If you read all the statutory requirements, national and local guidance, there are three words that are repeated when it comes to getting people to participate in the NHS:  ‘Inform’, ‘Involve’ and ‘Consult’. ‘Inform’ is nearly always a part of a process of involvement or public consultation. ‘Involvement’ often takes the form of pre-consultation engagement, or user involvement, in the co-production of services. ‘Public consultation’ has become the formal, scary bit, which happens at the end of a (quite often prolonged) period of pre-consultation engagement.  My argument is that if we reconsider each of these aspects of the duty to involve through a digital first lens, we will see that here are some real opportunities for people wrestling with the general duty to involve.

‘Informing’ and digital first engagement

With digital first engagement complex issues can be broken down into more digestible chunks, which is more suited to a world where people are short on time. No longer should we expect people to read through a two hundred page consultation document in order to have all the facts and figures at their disposal before taking part.  Instead, information about proposed changes to health services can be presented in short videos, infographics, summary documents, listicles, pictures, blog posts. And the good news is that all this content can be shared easily too – making even more people informed. Types of Digital Content for Patient and Public Involvement include:

  • Blogs
  • Short videos
  • Infographics
  • Case studies
  • Podcasts
  • Vlogs
  • ePamphlets
  • Listicles
  • Pictures
  • Interviews
  • Animations
  • Micromovies

‘Involving’ and digital first engagement

True involvement takes more than just an online survey. It requires time for reflection and space to deliberate the issues. Thankfully, done well, digital-first engagement can create a very productive environment for patient and public involvement. As Imelda Redmond, National Director of Healthwatch puts it, “Good engagement is about much more than carrying out formal consultations. It’s about a mindset that puts people’s experiences at the heart of decision making every single day.”

So what kinds of things can we do online to help people to be involved? In addition to helping people to be more informed about a subject, we can create online environments for people to deliberate, either from the comfort of their own home or even during their commute. Examples of online environments for effective involvement in health and social care include:

  1. Citizens’ Assemblieshosting citizens assemblies online creates a great place for people to deliberate complex health issues or suggest ideas for changing policy on difficult topics like closing a hospital or rationing of healthcare. Online they can easily take part in discussion forums, share ideas (using ideation tools), take part in quick polls and share their stories, which all creates a more productive environment for debate
  2. Focus groups   – online discussion forums are a great place to involve people in more depth, generate qualitative insight and encourage cross-fertilisation of debate and the sharing of experiences of health and social care
  3. Citizens’ Panels – normally consisting of a representative sample of say 1,000 to 1,500 people these were made to run online! Members of the panel can be encouraged to read, watch videos and listen to podcasts, all in a secure environment,  before sharing their opinions via surveys, opinion polls, discussion forums, ideas tools and so forth. If they get stuck they can ask the host for clarification via a questions tool. This is all radically transparent and creates a sense of genuine involvement
  4. Deliberative Polling – this involved around 500 people, selected using a random sampling technique, taking part in a multi-stage survey. A simple approach would be for the participants to take an online survey after registration, before taking part in various activities, like ideas tools,  discussion forums, storytelling etc. After a few weeks of deliberation, they would then complete another survey, capturing their informed opinion.
  5. Citizens’ Juries – these run like a traditional jury and are ideal for involving people in more complex and/or controversial issues, via their phone,  laptop or tablet! An online citizens jury would consist of about 17 people (selected by lot) who would be presented with facts, for and against, in the format of documents, video testimony, questions and answers and personal narratives.  The jurors would deliberate in a private forum before coming to a decision. For example, whether or not to provide an expensive but potentially life-saving drug to local residents
  6. Community panels –  by building a database of interested residents you can quickly select a panel of people to get involved in a project at any time and at short notice.  By collecting their demographic information and areas of interest (a.k.a registered participants) you can set up panels of relevant people to get involved in tough decisions about changes to services or priorities for the future of local health and social care, for example.   These communities often look at an issue through a different lens to the easy to reach people who normally shout the loudest!
  7. Surveys – and then there’s the much used and abused survey. In itself it is not a very curious way of engaging people, however,  online, it can be given a new lease of life.  People can be invited to sign-up to a project and take part in a survey environment which encourages them to read e-pamphlets, watch videos, and ask questions before completing the survey. The online survey can also be made more engaging and informative by including pictures, videos, maps and documents. All of this helps people to feel more involved in an issue before “having their say” by completing the survey!  

So, a digital-first approach to patient and public involvement is perfect for using multiple online tools like discussion forums, ideas tools, storytelling and so on to get people more deeply involved in what are often tough conversations about health and social care.

Public consultation and digital first engagement

‘Public Consultation’ and digital first engagement

Often,  when it comes to health and social care, informing and involving is a necessary but not a sufficient condition of the duty to involve. In addition, a public consultation is required.  And for important changes to services and transformational programmes, this often follows a long period of pre-consultation engagement.  For managers and senior decision makers in the NHS when this formal public consultation happens their main concern is sticking to national guidelines, best practice and legal principles.  Fortunately, a digital-first approach to public consultation has many benefits, helps to adhere to best practice and aligned with the Gunning Principles could keep you out of court!

Benefits of online public consultation for health and social care

  1. It creates a safe place for public participation, free from trolls and personal harassment.
  2. It becomes a safe haven for facts and figures to help people give your proposals intelligent consideration, free from fake news!
  3. It fosters an environment for deliberating the issues as opposed to harmful, aggressive, debate and argument.
  4. It allows for people to contribute via multiple dialogue methods, like discussion forums, stories and ideas, making the consultation more open, transparent and curious in nature.
  5. It enables people to add their details to a participant database so that they can stay informed, be alerted to new opportunities to take part and be told about the findings.
  6. It allows for inbuilt analysis and reporting as well as a comprehensive audit trail of people’s responses.

Best practice online consultation

Best practice consultation has always been about the right people, the right methods, the right questions, the right time and providing the right feedback.  It’s almost the same in a digital-first world.

Right people

Using digital outreach we can make sure that our consultation involves people from all walks of life and not just those people with the loudest voices, who are willing to turn up to a community hall on a dark and rainy Tuesday in February!  We can use digital stakeholder mapping to spread the word about our consultation and get key stakeholders and interested citizens involved. Social media advertising can also be used to raise awareness and increase participation, from a more representative sample.  So you see, online consultation can play a key role in ensuring our approach is inclusive and reaches out to the silent majority and unheard voices.

Right methods

Online public consultation is perfect for creating safe places for public discourse where people can deliberate using a  variety of methods such as ideas tools, discussion forums, and storytelling. They can take part in quick polls and also seek clarification by asking questions. If it is a place-based consultation they can add pins on a map, to express their point of view. All of this offers the consultee so much more than just an online survey (which if left to their own devices tend to harness reactionary and polarised opinion) by creating a place for deliberation and exchange of opinion.   Indeed one of the benchmarks for a best practice consultation is that it uses a variety of ways for people to take part – seldom will a survey on its own be enough.

Right questions (or right content)

For online consultation, we can change this to the right content. A digital first approach to public consultation helps you to break your consultation narrative down into easily digestible chunks. This helps people to give your proposals intelligent consideration. So for best practice we would expect to see short videos, podcasts, pictures, infographics, listicles, blogs and vlogs and so forth being used to get people involved in a meaningful way coupled with engaging questions.

Right time

In a digital first world we have to reconsider time.  For example, rather than a customary twelve week period, during which people can comment on your proposals, once, by filling out a survey, in a digital first world the consultation period becomes more dynamic.  Different discussions and opportunities to participate will take place during different weeks and on different days, people will have time to ask questions, download documents and watch videos – in their own time. They can check in and out of the consultation as they choose and respond in a variety of ways.  By default, the consultation becomes more responsive to what people say and do and is less fixed on the mere completion of a survey by X date.

Right feedback

Inbuilt analysis and reporting, together with a participant databases,  means online public consultation is designed for good feedback. Tailored newsletters can be sent to consultees, explaining what was said, what was done with the findings, what couldn’t be done and how the consultation made a difference to the final decision(s).

What about The Law?

And what about The Law?

Aligned with the Gunning Principles, digital first public participation can bring about fair – and lawful – public consultation.  It can do this by:

  1. Avoiding pre-determination – By offering alternatives to a just a survey, engaging early when proposals are at a formative stage and using a variety of dialogue methods people will feel that they have been listened to and participated in a genuine process, instead of a done deal.   
  2. Creating a perfect environment for promoting  “intelligent consideration” –  It enables public bodies to demonstrate that they have furnished participants with adequate information to permit intelligent consideration and response. Especially, as it allows them to move away from relying on, hard to digest consultation documents and instead break their argument down into snippets of useful (shareable) information – all held together in an array of information widgets.
  3. Rethinking adequate time – In a primarily online environment, people can participate in more varied ways, faster and complete multiple “check-ins” rather than just one hit participation with a survey. This makes the consultation period a time for debate and reflection. The whole consultation window then becomes a deconstructed survey, where people offer their quantitative and qualitative opinions via multiple activities in one consultation period.
  4. Allowing for open and transparent conscientious consideration –  Online consultation creates an environment which supports conscientious consideration.  There are more options for feedback using infographics, video, pictures, blogs and so on. The whole process of “you said, we did, we could not do” can be more engaging and targeted, for example, by sending e-newsletters to registered participants and followers of the consultation project and or publishing updates via a news feed and an online Q&A.  
The future is bright

The future is bright

Yes, the future is bright for patient and public involvement in health and social care – a digital first approach can be beneficial to informing, involving and consulting patients and the public.

But there is a threat to this bright future.  Many managers and senior executives continue to think that online consultation and patient engagement is about having a fancy looking website, which says all the right things with just a link to a survey. But, in the last few years we have learned that this is a dangerous approach with dissatisfied stakeholders taking to Twitter and Facebook to try and get involved – the way they want to. Sadly, as is well documented, this has left everybody disappointed and searching for alternatives.

So now is the time for clinical commissioning groups, hospital trusts and specialist commissioners to rethink their approach, by going beyond just-another-survey and creating safe places for online participation, which are designed to foster meaningful engagement and best practice consultation.

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