Reputation – maintaining or rebuilding trust in the NHS

Introduction

NHS Trusts are by their very nature in the public eye.  This is because of the sensitive and responsible nature of the work they do and the money they administer on behalf of the taxpayer.

As well as the constant service pressures, there is now the current recession and the consequent pressure on the NHS to achieve savings to contribute to its own future growth to meet health demand. This will put additional pressures on NHS Trusts that most will not have experienced for more than a decade. In addition, many public services are recording higher levels of public mistrust.  An environment in which this is the main narrative may weaken the ability of NHS Trusts to influence the political agenda when big decisions on public spending priorities are required.

There are also specific challenges which individual NHS Trusts  sometimes face, such as a very public crisis. The Mid-Staffordshire case may have been an extreme example but often issues arise relating to hospital cleanliness or a particularly difficult case that generates wide publicity even if it is not representative of the performance of the NHS Trust as a whole. Rebuilding trust is thus as important as managing the crisis in the first place.

This paper sets out advice and guidance that may assist NHS Trusts who find themselves in this situation.. It draws from the wide experience of TCC in tackling reputation management issues in the NHS and in the wider public sector.

A changing environment

Whilst the traditional local and national media will remain a key communications stakeholder for NHS Trusts, today’s reputational challenge is much wider than in the past.  In the 1990s constant rebuttal and seeking to set the media agenda was enough.  Communications was broadly a one way street.  “Spin” was king. However a public backlash against that culture, promoted by some within the media itself, as well as the rise of a genuine 24-hour media is forcing a change.

Today issues go much deeper as higher levels of accountability are demanded by the public which includes many individuals and groups making the most of modern communications techniques. There are new challenges that need to be addressed:

  • Web-based new media. There is a growing importance of web-based local media. This is wholly different to the one-way communications of newsprint.  Issues regarding good or poor standards in one area can be picked up by a blogger and used as ammunition in another. .
  • The rise of indirect stakeholders and single issue groups. These have increased in number with a strong agenda around dignity, respect and rights. They seem to be trusted by media and public alike - even when they have little legitimacy - simply due to the fact that they are not perceived to have a vested interest.  At the same time studies show that more people rely on other sources of information such as trusted word of mouth from people they know.

And in the NHS there are other key factors that impact increasingly on the issue of reputation:

  • World Class Commissioning for Primary Care Trusts. The standards expected of local NHS commissioning bodies and their need to be seen to respond to the patient experience agenda.
  • Patient Choice. This is increasing as a result of public policy, greater patient and public expectations and the development of technology

These factors are promoting far wider and deeper scrutiny of institutions and NHS Trusts are not exempt. Traditional public relations tools are less effective in addressing these challenges. What were formerly operational risks resulting from failed processes can now manifest themselves as reputational risks whose costs can have a substantial impact on an organisation far in excess of the original failure.

Often managers are in a strong position to spot potential challenges but they can sometimes fail to recognise their significance to the Trust’s reputation.  Communications strategies may be held back by lack of consistency in tracking and quantifying reputational risk as well as lack of accountability. As a result, responses to reputation issues can be short term, ad hoc, and defensive.

NHS Trusts are often reliant on small central communications teams  that do not have the resources to monitor or examine a wide range of reputational threats with sufficient sophistication. Traditional PR spin cannot deal with many public concerns which must often be addressed by changing the way the NHS Trust operates and through conducting two-way dialogues.

Most organisations track press coverage, and many are beginning to monitor the multitude of web-based voices. This is straightforward.  The bigger challenge is preparing to meet serious reputational threats, whose potential frequency and cost have risen dramatically given the greater likelihood that stakeholders, including regulators and politicians will want to be seen to be taking action and encouraged  by traditional media feeding off new media. These threats might take a variety of forms relating to anything from perception or performance to  bad news or health scares.

Modern reputation management

Reputation management is not just about crisis management.  It is about a long-term strategy to build a relationship with a range of stakeholders from the local community to the local commissioners and on up to those on the national political stage.

Fundamentally this requires much greater intervention in public debates. Instead of allowing single-issue interest groups to control the conversation, there is a need to engage far more and set out the NHS Trust’s position far more clearly to raise awareness of the difficult trade-offs they face. Identifying third parties who can express this would add to the authenticity of the debate even if that may mean letting go of parts of the debate and trusting others to say it for you.

The key thing to do is to put in place an effective early warning system to make the NHS Trust’s leadership aware of reputational problems quickly.  To prepare for and respond to threats, our experience suggests that health providers and other public sector bodies should prioritise the following:

  • Set up an early warning system about reputational threats across the organisation – and analyse that information in a more sophisticated way
  • Assemble facts and data to provide a good understanding of key stakeholders, including the general public, and help to prioritise communications and engagement resources
  • Focus on the issues that matter most to stakeholders. This may require an emphasis on transparency and accountability. “We are listening and we are responding”
  • Be seen to take action to mitigate potential issue in a very clear and direct way
  • Seek to influence stakeholders beyond traditional one way PR with a strong emphasis on two way dialogue.
  • Develop alliances with new partners including local organisations, local NHS Trust members and patients that add endorsement and authenticity to the message

Present the facts clearly and objectively . If appropriate, use performance indicators and patient experience metrics to reinforce the message. Quantitative measurements promote effective comparisons and help NHS Trusts identify potential issues or performance gaps. In other words, a commitment to good communications can add to culture change that leads to a more patient responsive performance.

The above analysis may lead the NHS Trust to conclude that a good story should be told or alternatively that it needs to refrain from a marketing strategy until it has taken action that makes for a stronger narrative. An NHS Trust can also assess the cost of potential reputation issues, , such as the public refusing to use its facilities through loss of confidence. Nowadays the voice of an NHS Trust needs to emphasise:

  • Actions: these speak much louder than words. Resolving an issue is more effective than just talking about it.
  • Authenticity: speaking with a voice that demonstrates that the NHS Trust is open, honest and on their side.
  • Dialogue: the days of just broadcasting a message are over. It is ongoing conversations that count.  These need to be two-way and need to respond to feedback.
Actions

Reputations are built not just on communications but most crucially on the actions taken. Stakeholders can see through PR that is not backed up by real and consistent deeds. From our research we often find that patients and public believe that NHS bodies rely too much on traditional PR. They also tend to be critical of NHS Trusts not sharing enough information about their plans. Transparency in such matters is crucial. Sometimes it highlights a mismatch between public expectations and local NHS Trust performance and therefore leads to calls for action. At the same time it can convince stakeholders that the NHS Trust is improving performance or help build goodwill to provide a degree of cover against future bad news.

Authenticity

Whether it is avoiding management speak or getting frontline staff to speak on behalf of the Trust in certain situations, projecting a message that comes across as genuine and honest is now what counts. The same action should not be repackaged and re-released as rehashed news. Each step taken should be a unique and new media event.

Dialogue

In order to hold effective ongoing conversation NHS Trusts will need to:

  • Enhance their listening skills so that they are aware of emerging issues
  • Reinvigorate their relationships with key stakeholders
  • Go beyond traditional PR activity by developing and sustaining a network of supporters who can influence key constituencies

These will demand  greater sophistication and coordination of reputation efforts which might involve:

  • Gathering intelligence  as a team effort – not just through the communications department but by the NHS Trust as a whole – technology and networks should help facilitate this
  • Segmentation to understand stakeholder concerns
  • Committed senior leadership stressing a clear difference made by the service provision of the NHS Trust whilst promoting wider NHS values

Understanding stakeholders

Reputations are built on perceptions often driven by strong emotions so rational issue analysis is not enough. NHS Trusts must also know if they are meeting the expectations of key stakeholders.  These will include not just traditional stakeholders (patients, employees and commissioners ) but also the more indirect ones such as the voluntary sector and the local and new media.

People have unprecedented access to information now and may therefore be interested in a surprisingly wide array of issues.

Each kind of stakeholder will have specific perceptions and concerns: For example

  • Board members might ask if reputational issues will affect their Trust’s long-term performance.
  • Regulators or commissioners could worry that the public thinks they should take action against an  NHS Trust
  • The media might criticise the NHS Trust on non-clinical services.

There are different ways of identifying the perceptions of each kind of stakeholder and their root causes:

  • A detailed press analysis can help Trusts understand the positions of journalists and editors on key issues
  • Discussions  with regulators or commissioners can clarify their concerns

Qualitative and quantitative patient experience research can provide an understanding of the views of the wider public

Who are your stakeholders?

Too often the list of stakeholders is underestimated. A communications benchmarking exercise may be the best way to clarify this. However, for the purposes of this paper, a general list of stakeholders is likely to include:

  • Patients, carers and relatives
  • The wider public
  • The Trust Board
  • Clinical staff
  • Senior managers
  • Wider staff
  • FT Governors (for those that have them)
  • FT Members (for those that have them)
  • Local and regional commissioners
  • Other healthcare partners, including Department of Health, Strategic Health Authority, Care Quality Commission, Monitor, Patient Voice Groups
  • Local elected representatives – MPs and local authorities, Health Overview and Scrutiny Committees
  • GPs
  • Media (including internet, newspapers, radio, TV)

Voluntary, community and faith sector groups

Segmenting stakeholders

It is important to appreciate that an analysis of how patients and members of the public feel about the Trust needs to be based on more that the  standard marketing segmentation. – Hospital care is a more emotional issue than just a simple market transaction.  It is much more like a segmentation of voters for a political campaign where one might segment groups over a range of issues and their perceptions regarding it: For example

  • Concerned about non-clinical issues
  • Concerned about key performance issues
  • Concerned about current/future provision
  • Ambivalent towards the Trust
  • Disinterested
  • Hostile

Matrices can then be designed that assess perception of the Trustagainst the level of participation or influence so as to prioritise segments to target.

Engaging influencers

Formal marketing and PR do still play an important role in managing the reputation of a Trust but when it responds to serious threats and needs to rebuild reputation it  should use many other means of spreading positive messages about its activities quickly.

In general, credible third parties speaking for the NHS Trust can boost its reputation much more easily than its own PR or communications department. This can take a number of forms:

  • General public support. Support from the public mobilised through blogs, posters, stickers, and interactive websites,
  • High level influencers. Third parties high standing to reinforce key strategic messages. Partnerships between the hospital and elements of the voluntary sector, such as League of Friends (and FT members where these exist) can be important not only because of their credibility but also because they can alert it to performance gaps
  • Organisations. A network of positive relationships with credible third party organisations (such as journalists and the voluntary sector) can also help the Trust get out its side of the story when crises do hit.

Other channels might include influencing specific bloggers, using the organisation’s blogs or Facebook pages to start conversations with public and patients and reaching those in more specialist communities through forums and discussion boards.

Managing a crisis

And what then happens when a crisis does occur? Reputation management as well being a long term strategy also allows one to be better prepared for future crises. The preparation one has done should enable the Trust to identify the problem earlier in the news cycle as well as having the local network to disseminate its side of the story much more rapidly.  This is the most reliable way to start the rebuilding of reputation again.

In terms of practicalities the following elements are important to deliver quickly:

  • An early demonstration of openness and honesty so as not to make a bad situation worse
  • Establishment of an  incident team bringing together senior management and communications professionals with the authority to respond as well as monitor reaction
  • Early development of the Trust’s narrative as well as messages that respond
  • Preparation of Q&As to be able to respond quickly and consistently to anticipated  questions from stakeholders

The document below sets out some of the responses a Trust will require in dealing with the aftermath of a crisis as well as starting the process of rebuilding reputation.

Reputations-1-1kurg.pdf

Conclusion

In an increasingly complex world, no single kind of approach is likely to be sufficient to deal with fast-moving situations. NHS Trusts must instead initiate a coordinated approach that can quickly identify reputational issues and ensure responses are included in broader strategy, operations and communications.

To achieve the necessary coordination, a senior member of the corporate management team should be accountable for such efforts.  The chief executive is increasingly likely the right person to lead the NHS Trust’s overall reputation strategy, ideally with the support of a board sub-committee focused on it. This may seem a large investment in time but, in today’s climate, with reputational issues more likely than ever to threaten a Trust’s viability, that degree of effort can be essential.

Download the full article Reputations.pdf

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Last Updated on Thursday, 17 September 2009 16:22