April, wrote TS Eliot, is the cruellest month, and for many in the NHS this brought new resonance when the news agenda in April of this year seemed dominated by just one story - cash crisis and related job redundancies. While rumours of deficits had gradually been building all year, that month the story suddenly hit all the headlines. It brought with it a concentrated period of political wrangling in the build-up to the local elections on 6 May.
Finally, last week, the extent of the cash shortfall emerged, with a third of all 566 NHS organisations failing to break even, bringing the total NHS deficit to £512m - double the amount of a year ago. Government demands that these shortfalls be repaid have already sparked more newspaper comment.
In essence it has become a major media crisis for the NHS and Government. It began with the Government denying that a problem even existed (a tactic that became a personal PR problem for Health Secretary Patricia Hewitt). Alongside this were individual hospitals with their own PR woes.
Here, PRWeek examines the comms strategies, and outcomes, of the three key players in this extraordinary period: the Department of Health; the individual trusts affected by financial problems and how they tackled fears of job cuts from an internal comms point.
Department of Health PROs did not want to talk to PRWeek for this feature, and so it has made it difficult to put across their side of the story.
Department of Health
The DoH faced some tough issues: DoH-arranged GPs' salaries (some at £250,000); the spending deficit forcing the NHS to adopt its ‘Agenda for Change' reforms; and the personal standing of Hewitt.
At the start of the crisis, the media were divided over who to blame. Some papers were not overtly anti-government; they said mismanagement, not a lack of funds, was at fault. A YouGov poll, conducted in mid-April for The Daily Telegraph, found that 77 per cent of respondents believed NHS problems were a result of bad management; only 16 per cent thought insufficient funding was the reason. Similarly, a Mori poll carried out between 20 and 24 April found that 64 per cent of respondents believed the NHS is not lacking funds, but that ‘too much of it is wasted'.
But, of course, the DoH itself also came in for a battering. A week earlier, an article in The Daily Telegraph quoted the former chairman of University Hospital of North Staffordshire, Calum Paton, as saying that government was ‘wrecking the NHS through bureaucracy and contradictory policies.'
Although Paton was defending his own record - he had resigned after his trust revealed a £15.5m deficit and the need for 1,000 job losses - the criticism came at a bad time for Hewitt. That day, the same newspaper reported that she had visited just 11 hospitals in her 11 months as health secretary. The following day, the DoH's press officers announced that she would now visit one hospital a week.
The mounting bad news stories and a reactive DoH forced Hewitt and Tony Blair to take control of the news agenda. On 12 April, some of the troubled trusts were invited to No 10 for a meeting. It was also announced that the 28 Strategic Health Authorities would be reduced to ten. By now though, talking to the trusts was too late, while the reduction of authorities was criticised by healthcare think-tank Kings Fund for ‘throwing the NHS into more turmoil'.
On the same day, Hewitt gave an interview to the Evening Standard, pushing the line that change was necessary and that hospital trusts had to work more effectively. She pinpointed trusts in west and central London that had overspent and been bailed out by those in east London. Hewitt added that some trusts had been keeping patients in hospital for too long, which resulted in hiring too many costly agency nurses. But the biggest PR disaster came two weeks later when Hewitt released a statement saying the NHS had had its ‘best year ever' - days before she was to face 2,000 furious nurses at the Royal College of Nursing's annual conference.
According to The Independent's political editor, Steve Richards, the statement was a ‘stupid thing to say; a presentational error. She cannot lose the support of the people needed to bring about the changes [in the NHS].'
The DoH's reputation had already been damaged by the resignation of NHS chief executive and permanent secretary at the DoH Sir Nigel Crisp in March, saying: ‘I wish to acknowledge my accountability for [these] problems, just as I may take some credit for the achievements.' The Conservative Party alleged that Crisp had been made a scapegoat by the Government.
Then, on 7 May, The Observer published comments made by Hewitt's deputy Jane Kennedy, following the latter's resignation. She said: ‘For some time I've had disagreements with the way in which certain aspects of health reforms were being dealt with. When you are told you shouldn't be expressing your opinions, you realise the Government needs to get someone else.'
DoH: THE VERDICT
Darren Murphy, a director of APCO UK, handles public affairs for the NHS Partners Network, was a former special advisor to health secretary Alan Milburn for four years and then a Downing Street press officer. He says he has sympathy for NHS communicators, but is critical of their actions in this case:
‘Department of Health PROs suffer from having to deal with parts of the media which cannot write the letters N, H and S without adding the word crisis. Newspapers like the Daily Mail seem to think the NHS is conspiring against the country. That said, the DoH should have, since May 2005, been pushing the message that NHS reforms are radical and that the public should expect a shake-up now. They began doing that in December, but the process should have started sooner. The culture at the DoH dictated a strategy that it is better not to talk about how radical the plans were. I think that was a mistake.'
By mid-April, the sheer weight of announcements of deficits and redundancies created a picture that most hospitals were in trouble. Blair and Hewitt's fight-back day on 12 April was partly about putting troubles in perspective, emphasising that the collective deficit was only one per cent of NHS revenue, and that just 39 out of 303 trusts were responsible for half the estimated £623m deficit.
That day, trust chiefs gave media interviews to announce the measures they had put in place to drive efficiencies. But it was not enough to persuade The Sun - whose next-day headline screamed ‘Off their trolleys' - that a Bradford hospital was cutting costs by making patients walk in to surgery.
Nigel Hawkes, health editor of The Times, believes that trusts have generally taken a straightforward approach to announcing details of deficits and cost-cutting programmes. ‘The resignation of Sir Nigel Crisp opened the floodgates; since then, trusts have seized the opportunity to confess to over-spending and spell out what might have to happen to correct it. They had no choice - they wouldn't be able to hide financial irregularities from their local media in the new regime of freedom of information.'
Hospital trusts have taken a two-pronged approach to unveiling details of cost-cutting programmes. The Government's preferred message has reiterated that the NHS budget does not come from a bottomless pit and they accept they must rein in spending. But cannier PROs have sought to brief journalists with the wider context to the situation trusts find themselves in.
Mervyn Gamage, head of comms at University Hospital, North Staffordshire NHS Trust, had the unenviable task of briefing journalists about auditors discovering a £18m black hole in the trust finances - something that was swiftly followed by the resignation of the chairman and four non-executive directors in December. By March, it was announcing up to 1,000 job losses.
‘We were telling staff and local media back in January that our deficit would have an impact on staff levels, so everyone has been aware of the way things are going,' says Gamage. While Gamage says he and his team have never denied that local mismanagement is to blame for the deficit, he has tried to explain to journalists the reasons for the inefficiencies - the fact that the hospital operates on two sites, which means a lot of transporting of patients, being one of them.
He also made other criticisms: ‘We are doing more work than the Primary Care Trusts are paying us for. It means we have to find new ways to make short-term savings. The Government wants to shift care from big hospitals to the community. We're saying we might have to make people redundant.'
Gamage feels that coverage the trust has received from the local media has been fair. ‘Our local radio station has a dedicated correspondent who has come to all our meetings and understands the issues,' he said. But to the national media, he feels that ‘we are just another hospital with problems'.
Trusts: THE VERDICT
Alex Woolfall is MD, issues and crisis management at Hill & Knowlton. He says: ‘The best that any NHS Trust sacking staff and cutting services could hope for was a score draw, never a win - especially in today's media. Being open and transparent with the media and other key stakeholders is no guarantee they'll see things your way. When it comes to communicating bad news, the perceived honesty and integrity of the organisation in question can make a huge difference to the way in which it is treated. No wonder Gamage thought the coverage he got was "fair".
‘The strategy used by some trusts of pre-empting bad news by proactively setting the scene early on was a smart move. Exposing the dilemma of their situation meant that if the outside world didn't sympathise, they at least understood the issue.
‘But some trusts, such as The Royal Free Hospital NHS Trust, did less well. After announcing plans to sack 480 staff, the next day it advertised four jobs for risk managers with a total annual income of £160,000.
Unsurprisingly, the London Evening Standard and the Daily Mail attacked this. In a crisis, you have to constantly scrutinise everything you're about to do: "How will this be seen? What are the risks?" I suspect there was a disconnect at some stage on this one.'
For NHS employers trying to deal with the implications of their financial deficits, keeping staff up to speed has proved a challenge. News of Pennine Acute Trust's plans to cut 800 posts leaked to BBC Radio Manchester a week before the trust planned to announce it. Unions said the first time that many staff heard their jobs were at risk was on the breakfast news programmes.
The trust's head of comms Fin McNicol counters this, saying that once his team learnt of the leak, they emailed memos that reached staff on the late shifts, the night before the news hit the radio headlines. Briefings were arranged for the following day. Ann Mitchell, press officer for public sector union Unison, criticises this, saying it was ‘just not good enough'.
Managing the flow of information about redundancies has been tough because of the news value of the information and the consequent merry-go-round of rumour. The Royal Free Hospital Hampstead NHS Trust found that within half an hour of posting on its intranet details of its plans to cut 480 jobs, it started receiving media calls.
Mitchell believes the trusts' strategy of distinguishing ‘posts' from people in jobs has unfortunate implications for internal comms. ‘There's been too much double-speak about the impact of these cuts,' he says. ‘Trusts have been trying to minimise the effect of the cuts by saying that a proportion will be achieved by cancelling vacancies. But someone still has to do that task, and it just means that more work will fall to the staff who are left.'
Mitchell also feels that the DoH's commissioning of private firms to take on some minor operations adds fuel to the fire. ‘Staff are upset enough that they've worked hard to hit targets and are rewarded by being made redundant. When they hear that private firms are given preferential financial arrangements to NHS hospital trusts to carry out an operation, it feels like those firms are valued more than their jobs are.'
Observers point out that it is virtually impossible for internal comms professionals to be responsible for the morale of the workforce in the current situation. Asked if she thought that staff felt comms had been handled well, a Royal Free Hampstead NHS Trust spokeswoman said: ‘You'd get a different answer whoever you asked.'
Internal Comms: THE VERDICT
Michael Frankenburg, head of Ogilvy Internal Communications, says: ‘The trusts are in a difficult situation. It is just not possible to make people happy under these circumstances. In these impossible situations, the least worst outcomes favour the "best possible" ones, and there were mistakes.
‘Unnecessary delay between decision-making and communication is dangerous and wrong. Leaks were inevitable and once sprung, teams were playing catch-up. Getting emails on the late shift, or learning that jobs are at risk on an intranet, is not how I'd want to hear it.
‘There is an obligation to develop a shared language and taxonomy - and if PROs play with words like "post" and "job" - people will always assume the worst. But it's not the internal comms task to be responsible for an intangible outcome like morale. It is a leadership role to make people feel valued and supported in their work.
Getting senior management to accept this accountability may be the most important piece of internal comms they have to achieve.' n Note: Announcements concerning job losses have been contained in consultation documents. Trusts will now conduct three-month consultations over the detail with staff and unions.
NHS: Two months of Misery
17 March -
Health Secretary says cash crisis will not affect patients, the day after University Hospital, North Staffordshire NHS Trust announced 1,000 jobs would go.
24 March -
Unions call for crisis talks with Patricia Hewitt over NHS job cuts.
29 March -
Trafford General, the hospital opened by NHS founder Aneurin Bevan, announces that it will demolish 25 per cent of its buildings to make way for car parks.
6 April -
Worcestershire Acute Hospitals NHS Trust says it would have to shed 720 jobs over the next 12 months to balance the books. The trust has debts of £31.5m.
12 April -
PM holds crisis talks with heads of NHS trusts. Think-tank Reform predicts that the NHS will need to shed 100,000 jobs in the next three years.
13 April -
Sandwell and West Birmingham Hospitals NHS Trust says it may have to shed up to 800 posts.
18 April -
The Daily Telegraph quotes a Government official claiming the NHS's troubles will get worse and that the next phase is hospital closures. It is denied by the DoH.
23 April -
Hewitt says the NHS is having its ‘best ever year'; the same day the Royal College of Nursing reveals that 13,000 NHS jobs are on the line.
24 April -
DoH Census shows a rise in hospital staff numbers since 1995. East Sussex NHS Hospitals Trust announces a plan for 250 job cuts.
26 April -
Hewitt is heckled at the RCN conference. Norfolk and Norwich University Hospital Trust announces losses of 450 jobs.
28 April -
Barking, Havering & Redbridge Trusts reveals its plan for 650 job losses.
7 June -
NHS deficit is said to be £512m