NHS SPECIAL: Keeping the faith - PROs at the NHS are a front-line defence in maintaining morale across the service. Andy Allen examines how they are tackling negative press

Nye Bevan, creator of the NHS, famously warned upon its creation that the sound of a 'bedpan dropped on an NHS ward would reverberate around Whitehall'. If he had written those words today, he might have been tempted to add that the clattering of the falling bedpan would simultaneously resound around the newsdesk of the local newspaper.

The NHS has always been a political football - these days it often appears to be a whipping boy for the media as well. Battered by squabbling politicians, headline-hungry media, reams of new legislation governing how they do their jobs and numerous tiers of management, NHS morale is more under siege than ever.

And, given that the tasks of dealing with the media, briefing the politicians on crises, internally communicating the new legislation and defending the bean counters inevitably fall to press officers, it is they who are the first line of defence for NHS morale.

For many PROs in the NHS, morale is the paramount issue of their working lives. Wakefield Health Authority head of communications, and a member of the management committee of the Association of Healthcare Communicators, Anne Akers says: 'Almost everywhere you go, the NHS is one of the biggest local employers. Each member of staff is a potential ambassador for their hospital among their families and friends.'

Mark Purcell comms director of NHS specialist agency Jonathan Street, echoes the importance of having thousands of staff working as 'ambassadors, rather than working against you'. According to Hugh Lamont, NHS Executive North West head of communications, '75 per cent of criticisms of the NHS come down to a failure of communications'.

The problem is that resources for the NHS at large have not kept pace.

Public dissatisfaction is worsening, according to a Gallup poll carried out last December. The study revealed four out of ten people believe the NHS is 'getting worse'. The number of people who consider the NHS a failure has doubled since Labour came to power in 1997, the study says.

The political and media pressures surrounding NHS issues are well illustrated by the recent case of Rose Addis, the 94-year-old patient who became the subject of heated House of Commons exchanges between Tony Blair and Iain Duncan Smith.

Lamont says this case shows how the pressure on the NHS has dramatically intensified during the past five years: 'Since the Labour government came to power the NHS has been more relentlessly under the spotlight than ever before. Maybe it's down to raised expectations. Twenty years ago, people would complain to the hospital itself. These days they will go straight to the press. We're also seeing a litigious culture that never existed back then.'

It is often said that the NHS is permanently in crisis, and ironically, as far as communications goes, managing the crises makes it hard for PROs to look much beyond day-to-day media relations.

The majority of PROs acknowledge the importance of extensive internal communications alongside efficient crisis management. But just as resources throughout the NHS at large are frequently unable to meet demands, so PR resources frequently allow for only crisis management to be energetically pursued.

Akers says: 'We find there aren't enough of us. Compared to local government, for example, our teams are very small. We're all aware we should start with our staff and that they need to know what's going on before they hear it from the newspapers, but there's not the time. So often it comes down to fire fighting.'

And far from fighting fire with fire, many PROs feel unable to respond to critical and possibly unfair stories with much more than a meek pledge to investigate, such is the impact of the doctrine of patient confidentiality on NHS media relations.

As one clinician, who does not wish to be named, says: 'It sometimes feels like we've sworn Trappist vows of silence rather than the Hippocratic oath. Patients are free to go marching to the media with their complaints. In the resulting stories clinical staff are usually implicitly to blame - and they'll certainly feel the finger is pointed at them.'

There are other negative spin-offs besides. Wembley Observer news editor Rob McNeil says: 'The way it works in newspapers is that if an editor asks you to get an answer to a question, you get it wherever you can. If the hospital won't provide it, you go doorstepping and that obviously affects the way NHS staff perceive the press.'

Since Tony Blair controversially stepped in to defend the Whittington Hospital in the Rose Addis case in January, the issue of confidentiality as it affects the NHS's ability to respond to criticism has gained a higher profile. But even before Blair pointed out hospitals had the right to answer their critics, guidelines had already stated that when a patient or their family has gone to the media, health staff are entitled to give their side of the story, providing the facts do not extend beyond those already in the public domain.

Yet those guidelines are confusing and may still limit a fair response, according to some PROs. Akers believes there is still a large amount of inconsistency among NHS communicators in how thoroughly confidentiality is applied to media relations. The uncertainty and tendency to err on the side of caution is excacerbated by the fact that breaking confidentiality is a sackable offence.

There is help at hand though. Even before the Addis case, the Association of Healthcare Communicators had set up a working group to provide new clearer guidelines on this issue. The guidelines should emerge in the next few weeks.

This will not solve all the communicators' problems. One major issue affecting NHS morale among clinical staff is the perception that management tiers consist of overpaid bean counters. Relations were further strained by media coverage at the end of last year pointing out that more than a quarter of NHS trust chief executives earned six-figure salaries in the last financial year. On average, chief executive pay rose by 5.3 per cent, compared with a rise of just 3.3 per cent for doctors.

Clinicians point to an 'us and them' culture. Some also believe the PR departments' response to criticism tends to protect management rather than clinicians.

Akers agrees that as PROs generally answer directly to the chief executive, there can be a risk that clinicians' voices are not heard. Ideally, she says, there should be a PRO with separate responsibility for clinical communications, but scarce resources mean this is relatively rare.

On the other hand, management often suffers an even more hostile press than clinical staff, according to Carol Grant, partner at agency Grant Riches. The agency was last year involved in the successful marketing relaunch of the NHS Management Training Scheme.

Grant says: 'Managers are often an easy target for bad publicity. There's a sense in some quarters that clinical staff save lives and management do accounts. Their contribution is often overlooked.'

By careful handling of crises, however, management can sometimes prove its worth to staff just as the headlines try to do their worst. Leigh McGowan, head of communciations at the Queen's Medical Centre, Nottingham, recalls the day in 1994 when baby Abbie Humphries was snatched from the QMC maternity ward five hours after her birth.

Within 50 minutes of Abbie's abduction the media were calling. The story went national, then international. An immediate decision was made for then chief executive David Edwards to act as sole spokesman for the hospital in the first instance. McGowan dealt with follow-up calls.

'It worked very well. It had the effect of making clinical staff see their chief executive stand up and be counted,' he says.

Facilities were immediately laid on for dozens of journalists arriving at the hospital. A liaison group was set up that could meet with police counterparts at short notice to react to any new developments. Importantly, McGowan believes, the dangerous 'information void' that appeared when the trail went cold at the end of a week was filled by the announcement that a new tagging system had been introduced in the maternity department.

Happily, Abbie was found 15 days later and reunited with her mother.

He points to the relationships built up during that period, underpinned by mutual trust, as a key element in effective media relations. Others agree this is crucial and stress the importance of media training for clinical staff to reduce suspicion of the press and teach them to take negative publicity less personally.

Often such training is provided by agencies such as Jonathan Street, which also provides crisis management, advice on public inquiries and lawsuits, and back-up media relations services on a retainer basis for around 30 NHS organisations.

Jonathan Street director Mark Purcell says demand for their services has remained constant over 20 years. The services of such agencies are often welcomed by hard-pressed in-house staff, struggling alone in their offices. But journalists aren't so sure.

McNeil says: 'From a reporters' point of view they're (agencies) good and bad. Good because you always get a fast and professional response, bad because you don't build up a relationship with them - and they're never indiscreet.'

So what next for the in-house teams as the NHS faces reorganisation?

With such a radical change there is plenty of scope for cuts in PR staff, but so far the omens look good. Akers points to developments such as the appointment of Sian Jarvis as director of communications for the Department of Health. Her primary role is to help ensure better communications between central government and the NHS locally - and many PROs are inclined to see her role as an indicator that the Government realises the importance of communications.

Akers isn't so sure all chief executives are convinced: 'It's getting better. But PROs are still getting asked to come up with communications strategies by chief executives that simply don't realise you can't have a communications strategy without a business strategy.

'And it can be hard to explain how you're adding value. It's all very well showing you're managing crises - it's harder to get recognition for the crisis you've just averted.'

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