Politics, power and persuasion: making a change in healthcare

Say you have a big idea and you would like to see it happen. How do you do this?

People may need to change their behaviour. To do that rules and incentives might need to be altered. The right arguments will need to be made to the right people at the right time so that a constellation of actions can be taken. To consider such a problem is to consider politics. In this way, an understanding of how politics operates can be very useful to healthcare professionals with big ideas.

If politics is the art of enacting one’s ideas, then power and persuasion are the instruments of this activity. Having power appears at first to be the best instrument to use. However the realms of persuasion and influence are often more important as, even with power one person’s reach is limited. Enacting changes requires the ability not only to alter one part of a system but to shape a discourse. Three recent examples from the highest levels of our own health service illustrate some important lessons.

The Health and Social Care Act 2012

The government faced unprecedented opposition to its reforms not only from unions but even from the medical royal colleges. They were forced into a ‘listening exercise’ over a major piece of legislation and eventually an amended bill was passed through parliament. Because of the changes made we are now left with a law that is likely to need revisiting in the future. Why did the government face so many problems here?

The genesis of this can be found in a recent speech made by David Nicholson, retiring Chief Executive of the NHS. He described how in the 2010 general election “political parties went round the country making promises of no change to a whole set of local populations.” In fact the intended reforms did not feature in any party manifesto or in the coalition agreement. Consequently, key stakeholders (including most of the prominent opposition groups) were not involved in the process of crafting the bill. They were taken by surprise when a fully formed and exceedingly complex piece of legislation appeared in 2010. The rest, as they say, is history.

Lesson 1: Engage with your stakeholders. Nothing happens without them.

The Francis Report

Many may have forgotten that the latest report is actually the last in a series of investigations into the events at Mid Staffordshire spanning 4 years. Yet there have been disagreements about some of the reforms the final report proposes. In fact the government did not respond individually to each recommendation and certain responses will not go as far as the report suggests. For example, the proposed legal duty of candour will apply to NHS trust boards rather than to individual healthcare workers. Why the apparent disagreement here?

The report is probably too long for each of its 290 recommendations to be considered over less than half a parliament. It is equally too high an ambition to have expected such an extensive and complex piece of work to have ended with just a few easy steps. It is accepted that the final report does well in recording what happened and analysing the root causes of events. Therefore this report is likely to be referred to in policy for many years to come. But it represents the start of the conversation for the NHS rather than the last word.

Lesson 2: Keep it simple. Avoid complexity. Good analysis is not the same as good policy.

The Keogh Review

Part of that conversation had already taken shape in the form of this report produced by Bruce Keogh, the NHS Medical Director. His inspection of 14 hospital trusts in England took only 6 months and its 8 ambitions have been well received. Not only that, but the methods used to conduct the assessments look set to become a standard for hospital inspections in the future. How has this document become so influential?

It is clear that many of the ideas implemented in the Keogh Review existed long before the opportunity arose to enact them. This can be seen from how rapidly the inspections were conducted. There was no need to consider academic questions of how best to inspect hospitals because these problems had already been resolved by the time the review was announced. The success of this review then shows how having an idea fully prepared and waiting for the right moment can greatly increase the success of an idea.

Lesson 3: Get the timing right. Do all the groundwork possible and then wait for your opportunity.

More than drawing out individual lessons, we can see from these case studies that holding power is neither a guarantee nor a pre-requisite for political success. Knowing that should bring hope to future policy makers.

Submitted by Rahul Bahl