Public Service Management: Good health care is all a matter of opinion: After consultations with doctors, consultation by market researchers. That's today's NHS, says Paul Gosling

THE PUBLIC SECTOR has always faced difficult choices about which services to provide, and how to deliver them. Health authorities are leading the way in a novel approach to this problem: asking the public, through opinion polls and other surveys.

In January the NHS Management Executive circulated a document entitled Local Voices, which called for 'a radically different approach' to consultation, involving the broader community in decision making. Although it is not yet obligatory, it is a clear indication of government thinking for the whole of the public sector. Health authorities are encouraged to be involved in a wide range of continuing consultation procedures to establish the public's service priorities, and to try to reflect these in the decisions taken. Recognising that opinion polls cannot be regarded as infallible, other consultation methods are also advocated including user panels, focus groups and patient satisfaction surveys.

Dr Geoffrey Carroll, director of public health at Mid-Essex Health Authority, says that directly consulting the public about service choices reflects the changed membership of health authorities. 'We've tried to partially substitute for the absence of members of the general public on our executive board. The non-executive directors come from a business background or administration, not to represent people.'

The rationing of health care is potentially the most emotive issue on which to consult the public. Dr Bobbie Jacobson is director of public health at the City of Hackney, in east London, which is conducting a survey of local views on service priorities. She says there are enormous ethical problems involved, especially in an area as poor as Hackney, where very few people can exercise the choice of using private health services. 'We asked people to put 16 choices into categories of importance, but they had difficulties, because people in Hackney can't go private if they want an abortion, for example.'

Those using the results have to be aware that the wording of questions and their context strongly influence the answers given. In an early Hackney survey respondents said that intensive care for premature babies weighing less than one and a half pounds should be a top priority. When the question was reworded and asked again, indicating the low survival expectations, this became the lowest priority.

Dr Jacobson said that survey results should not be used as the sole determining factor for choosing between priorities. 'Family planning is one of the most cost-effective services, but family planning figured low in our survey. But I wouldn't be prepared to propose rationing family planning on the basis of what the public says.' Another key problem is that survey respondents see the questions in very personal terms. If they, or a close relative, have cancer they prioritise care for cancer sufferers; others do not see it as so important.

The most useful consultation is of actual service users. Mind, which represents and lobbies for the mentally ill, also contracts with health authorities and local social service authorities as a service provider. Liz Sayce, policy director of Mind, said: 'We believe that users should be involved in all stages of planning, management and monitoring of services.' Mind goes beyond consultation, involving users on its National Council of Management, while service users also run training courses for professionals, to provide a users' perspective on services.

Ms Sayce believes even authorities that do consult do not always ask the right questions at the right time. 'A recent survey asked users what colour they wanted for a newly built acute psychiatric unit. They said they didn't want a new unit, they wanted different sorts of crisis intervention options. They were asked too late.' While some authorities still have a lot to learn, others have already moved a long way forward. 'In one health authority there is a users' charter, written by the users. A social services department has a service plan written by the users. There is a significant move away from the paternalistic pattern of service provision.'

These issues are essentially the same across the whole spectrum of public services. East Hampshire District Council's chief executive, Brad Roynan, sees surveys as particularly important for those parts of the public sector where services have been contracted out. 'As we become more an enabling authority, how can we enable for the community unless we communicate with them? In particular, we need feedback on the quality of contracted-out services. I'm very keen to use market research to test perception and communication, to check on service performance, and also to play a role in policy development. For example, the Government is very keen that local authorities do more on recycling, but it is not practical unless the community will support it in separating wastes out. We surveyed this, and we were surprised how strong the support was for waste separation.'

Surveys play an important role for the public sector as service providers who are not faced with the competitive disciplines of the market place. Mr Roynan said: 'When you are a monopoly supplier it is quite easy to have an ivory tower view of what people should have. You need to find out what they really want.' He adds that survey questions must build in information on the cost constraints, 'otherwise they'll say they want swimming pools and leisure centres, when you can't afford to do it'.

Leicester City Council, one of a number of authorities which are undertaking regular corporate surveys, feeds its results into an annually revised customer charter. The charter provides pledges to meet the service improvements demanded in the survey.

The 1991 survey concentrated on environmental concerns. Leicester's policy officer, Jo Dungey, said: 'This showed that dog mess was the key problem, followed by traffic-caused air pollution, traffic congestion and dirty streets and litter. We have now submitted a request for new by-laws to control dogs on parks. We have always found that whenever controls on dogs are proposed dog owners lobby very strongly against them. The survey, along with consultation meetings, provides evidence against dog owners to support the by-laws, which is important in asking the Home Office to approve them. The survey also led to management changes on street cleaning, and the purchase of new equipment.'

The largest market research surveyor of the public services is Mori, which now has 40 per cent of its turnover in this sector. Mori confirms there is an enormous range of surveys and consultation currently taking place to review and plan services, with about 100 local authorities using the company.

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