The keystone to success of the NHS Five Year Forward View


In architecture, a keystone is defined as the element that is introduced during construction that “locks the other elements in place and allows the whole to be self-supporting.”

keystoneIn biology, a keystone species is described as “having a disproportionately large effect on its environment relative to its abundance. Such species are described as playing a critical role in maintaining the structure of an ecological community, affecting many other organisms in an ecosystem and helping to determine the types and numbers of various other species in the community.”

If a keystone is absent, weak or allowed to decay – or if a keystone species declines – the effect can be catastrophic on buildings or ecosystems.

We contend that Listening and Engagement is the keystone to the success of the NHS Five Year Forward View – both at a national level and more crucially in individual local communities.

We are all familiar with individual tales of local and regional “service reconfigurations” running into difficulties and often having to be abandoned as a result of local opposition. Compared with recent history, these ‘little local difficulties’ will be a walk in a park compared with NHS England’s radical vision of multiple new Care Models, charged with “breaking out of the artificial boundaries between hospitals and primary care, between health and social care, between generalists and specialists.”

The good news is that, if Listening and Engagement is embedded in change proposals from the outset, the chances of success are greatly enhanced. But this means genuine listening and genuine engagement, not simply sham ‘consultations’ where the desired outcome is set out in detail in advance and “comments’ invited on it in full expectation or suspicion on the part of everyone concerned that the result will be “endorsement” of the proposed approach.

So what are the hallmarks of genuine listening and engagement? We put forward the following ten:

  1. Systematic identification and pro-active involvement from the outset of all potential interested parties – going beyond the “usual suspects”;
  2. Starting with a blank sheet of paper and open questions, not closed viewpoints on a ‘preferred’ solution
  3. Early engagement and honest debate – getting all views and disagreements out in the open early on;
  4. No hierarchies of opinion or view;
  5. Commitment to constant review, reflection and open collective discussion;
  6. Rigorous honesty about what is possible – both from a financial and a service point of view;
  7. Specific answers to specific concerns – rather than a general commentary;
  8. Willingness to openly acknowledge disagreement and explain rejection of options as well as set out only the areas of agreement or consensus;
  9. Preparedness to be unpopular with disproportionately loud voices – often the hallmark of special interest campaigns; and
  10. Investment in as wide as possible a range of listening and engagement activities and channels – new and old, modern and traditional, Social Media as well as paper.

If you are embarking on your own local process of engaging with the NHS Five Year Forward view, it might be a useful exercise to take these 10 items and check off just how many you are following.

There is a danger that, without active conscious planning and investment, Listening and Engagement will be allowed by default to slide down the list of priorities compared with attention given to tariffs, structures, care models and systems.

If this happens, as night follows day, NHS and social care providers will all too quickly find themselves being buffeted, battered and blown off course by the all too familiar pressures of local politics, special interest mobilisation, short-termism and targeted and well-organised defensive campaigns. (Note that we say it “will” happen, not “may” happen).

As the Five Year Forward View puts it “There are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government and of our other partners, both national and local”

A demonstration of the NHS genuinely playing its part will be whether it actively and consciously puts in place the keystone of Listening and Engagement.