KOHIN

3 An Outline of the Situation

The more imminent closure of the N&N began to be properly examined in 1990, when the Health Authority was required to review the situation. The decision that a single DGH at Colney would be the preferred option was made by the NHA in 1991, and this was presented to the public as part of the consultation process in 1992.

3.2 The Public Consultation in 1992
The NHA and the N&N Trust claimed that, 'The whole issue was fully debated in the public arena,' and that there was 'widespread distribution of a consultation document and leaflet'. (Stamp and Walker, 1997) However many members of the public were unaware of this issue until 1995 or 1996.

Rob Smith from the NHS Trust told me that a leaflet summarising the proposals was delivered to all households in the county, and that there was 'endless stuff' on Radio Norfolk and in the EDP. However, the attendance at the consultation meetings ranged from 6 to 40, and was a fraction of the hundreds at the KoHiN public meetings in 1996 and 1997. Rob Smith said that he had 'simply no idea' why this was. The fact that it was a choice between the N&N and Colney had been clearly set out, with banner headlines in the EDP. However, I learnt from a different source who had a contact on the NHS Trust, that "The consultation was not nearly as full and frank as the Trust suggested". (Interview X, 1998)

The poor turnout at the public consultation meetings did indicate that the problem had been with publicity and education, rather than apathy. The feeling was that although the civil servants had observed the statutory procedures, this had not been adequate. (Carlo, pers comm. 1998)

The actual rebuilding of the N&N was not covered by any of the five options presented in the consultation document. The first three options were for split-site hospitals, which was consistently portrayed as a very unfavourable situation with today's highly specialised and integrated hospital services. The fourth option of a single site at the refurbished and enlarged N&N was also criticised as providing a far poorer quality of patient health care. (NHA, 1992)

It was interesting that when I asked Rob Smith if dissatisfaction shown in the 1992 public consultation process would have made a difference, showing amazing faith in our democratic processes, he replied,
"If the District Council and the public bodies had come back and said 'no, this is terrible,' then the Health Authority at its public meeting could have carried that through, they would have listened to that public pressure, but in honesty there was none at that time." (my emphasis)
Needless to say, members of KoHiN did not share this view that the public were so adequately represented by these 'public bodies'.

3.3 Lack of public awareness
Graham Martin, Chairman of Colney Parish Council, told me, "We knew nothing until 1995." Geoff Clayton, who later became an extremely active member of KoHiN, also did not know that the N&N was going to close until 1995, although he was aware of the new hospital at Colney. The widespread lack of awareness had been what lead him to campaign, as he strongly felt that the public had not been consulted properly.

For many years the EDP and the Eastern Evening News continued to refer to the Colney hospital as 'Norwich 2'. This did not help the fact that many people were still unaware that the new hospital meant that the N&N would be closing. In addition to this, the issue was not in the limelight for many years, as there was little to report with the 'commercial secrecy' surrounding the PFI. (Hopkirk, pers comm. 1998)

3.4 Local opinion
Charles Clarke said that the closure of the N&N was one of the most common subjects brought up by voters in Norwich South when he was canvassing for the General Election in 1997. He has received several hundred letters about this issue, with about 90% being against it. (Norwich Labour Club, pers comm. 1998) KoHiN collected 30 000 signatures on a petition in a relatively short time. (KoHiN web site, 1998)

Letters to the EDP predominantly show much anger and unhappiness about the closure of the N&N, although there are a few dissenting voices, especially from those outside Norwich. Access will certainly be better for some people, and the ambulance service has said that they will be able to get to Colney quicker for the whole of the population that they serve. (Smith, R, pers comm. 1998) Both Graham Martin and Geoff Clayton were sceptical about this comment, pointing out that much traffic from the county will have to come through Norwich.

Malcolm Stamp at a public meeting in April 1996, stated that staff have not raised distance as a problem. (Denise Carlo's notes, 10 April 1996) Over 80% of journeys to the N&N are by car, and only 6% of staff walk. (Smith, R, pers comm. 1998) Staff that I talked to at the hospital were looking forward to the parking spaces they would be guaranteed at the new hospital, although some did regret the move for other reasons.

The main priority for staff at the N&N is for a new hospital with better working conditions. Most, especially at management level, are supportive of the Colney Hospital, although some staff members did attend some of the public meetings in 1996 and 1997, and did help the KoHiN campaign with leafleting. The local UNISON branch did pass a motion against Colney, although the minutes were later torn up as the meeting had not been properly advertised. (Carlo, per. Comm. 1998)

Dr Geoff Clayton had a personal policy of asking everyone at his various GP surgeries throughout the county what their opinion on the Colney Hospital was. He thought about 95% were against the move. (pers comm. 1998)

3.5 The feasibility of rebuilding the N&N
As KoHiN refused to concede that the rebuilding of the N&N was not viable, it commissioned Michael Innes, a nationally renowned architect. He investigated the feasibility of rebuilding the hospital on the present site, whilst keeping it in operation. As he was not particularly confident himself, and was operating outside his specific area of expertise, he consulted a quantity surveyor at City Hall, and some of his colleagues. They all approved his methods and confirmed that his figures were realistic. However, it was relatively easy for his work to be criticised, because any decision made differently could have a large effect, and there is great ambiguity as to how the calculation should be done. Indeed, David Walker, the Chief Executive of the East Norfolk Health Authority is still considering how the write-off figures for the current N&N properly should be treated. (Carlo, pers comm. 1998)

Michael Innes' study became central to KoHiN's campaign. They held a large public meeting on 25th April 1997 in Blackfriar's Hall, to educate the public that they had been misinformed and that there had always been another alternative to moving the hospital out of the city. KoHiN also publicised Michael Innes' work in leaflets and on posters, and an exhibition with details of the design was displayed for some weeks in Castle Mall. (Clayton, pers comm. 1998)

Andrew Stronach from the Eastern Evening News investigated the process that had led the NHA to claim that the rebuilding of the N&N was unfeasible. In 1992 the architects Povall Worthington had been commissioned by the Health Authority to assess the suitability of the city centre site for a 1600 bed hospital. The report concluded that it would be difficult, but that a 1000 bed hospital could easily be accommodated. (KoHiN web site, 1998) A spokesman for Povall Worthington told Andrew Stronach,
"High infrastructure figures were brought in and the mood was, 'let's build a new hospital.' ...We came to the conclusion that we could build the hospital on the same site with all the latest technology. It was completely practical and realistic. But they wanted 1600 beds...There was a big driving force for Colney because the consultants wanted it next to the University." (Eastern Evening News, 24 April 1997)

The message that the site was unsuitable was passed on from the NHA, to the RHA, to the NHS executive and on to the Health Minister, without any of them having seen the actual report. (Carlo, pers comm. 1998) The KoHiN web site states that the report is not in the public domain and has disappeared - even Charles Clarke has failed to find it.

The NHS Executive did provide a lengthily response to Michael Innes' proposal. Dated 12 August 1997, the report from Lynda Atkins, (business analyst from the NHS Anglia and Oxford Executive Assessment) carefully goes through the calculations Michael Innes used to claim that keeping the hospital in Norwich would save £100 million. Using many of his own assumptions, but adjusting for different land prices, and including the compensation payable to Octagon, the result was that the N&N option was £20 million more. Other problems the report pointed out were that the running costs would be higher at the N&N, and that its redevelopment would be such a high risk investment that it is unlikely funding could be found from private finance. The report also stated that Michael Innes' program of five to five and a half years for redevelopment "is extremely optimistic," and does not take proper account of factors such as the renegotiation of the PFI deal and the design period.

4 Decision Making Models

This would indeed be the argument of the NHA and the NHS Trust. An appendix in the 1992 public consultation document laid out the weightings used to appraise each of the five options. The criteria used included accessibility, 'environment' (for patients, staff and visitors), disruption, flexibility and research & development. The Colney Lane site scored about 60% more than the refurbishment of the N&N, (NHA, p28, 1992) although after the consultation with the public, the weightings were altered and this lead was reduced. (Stamp and Walker, 1997)

This assessment illustrated that the decision makers did present the background to their choice in an accountable way. Even with the different value the public might have had on criteria such as accessibility, the Colney Lane site still had a clear advantage within these terms. However, these criteria only considered the options with regard to the various advantages for patients, staff and visitors. Although the supposedly best site was chosen on these grounds, the wider consequences of the five options were not discussed.

4.2 Criticisms of the Rational Actor Model
The most poignant comment about the Rational Actor Model is that it is not only descriptive, but prescriptive. (Greenaway et al. p18, 1992) It may be how civil servants and politicians would like their behaviour to be viewed, but members of the public will often believe that there is more going on.

A relevant criticism of this model is that it does not properly take into account the difficulties of compiling and assessing information. A complete knowledge of all possible options and their consequences is a practical impossibility.

In June 1996 the Environment Secretary John Gummer announced the revised Planning Policy Guideline (PPG) 6, which requires that a 'sequential test' should be carried out before planning permission is given for a greenfield site. (See Box 3) Malcolm Stamp admitted at a public meeting that the alternative sites reviewed before the 1992 consultation did not include Nestlé. (Denise Carlo's notes, 7 May 1996) It seems doubtful that the option of rebuilding the N&N was ever investigated with much vigour. It was only at a meeting organised by Norwich City Council in late 1996, that a governor of Bignold School said that he would welcome a site change for his school, releasing land adjacent to the hospital. (Letter from Geoff Clayton, 1997) Although it is accepted that reality cannot easily adhere to the Rational Actor Model's complete possession of the facts, it appears that once the decision to move to Colney had been made by some in the late 1980s, little effort was made to investigate the other options.

As for the consequences of the various options, the NHA were not legally obliged to carry out an environmental impact assessment or a socio-economic survey of the effect of the closure of the N&N on the city centre. As their area of concern only involved issues directly associated with the hospital, it is unlikely that much weight would have been given to these effects.

Another criticism of the Rational Actor Model is that it sees government as purely hierarchical, and so ignores the possible conflicts of interest within the state. See 4.5 for a further discussion of this.

4.3 Bounded Rationality
This theory considers a further limitation of the Rational Actor Model; that it does not consider the defining framework in which decisions are made. This partly relates to the fact that many options may be filtered out because they are too original or novel (Greenaway et al. p21, 1992), such as Michael Innes' plan to rebuild the hospital. There is also the fact that individuals have personal values that may differ from those of their organisation, but which may influence the decision. A prestigious, new, state-of-the-art hospital may have been appealing for its own sake rather than from a careful consideration of what was best for the area.

4.4 The Organisational Process Model
This theory was created by Graham Allison to explain the Cuban Missile Crisis. It emphasises the effect of the routine that policy makers can fall into. "It is almost invariably easier to carry on following existing patterns of behaviour than to work out new ones." (Greenaway et al. p32, 1992) This could be why Michael Innes's rather radical idea of rebuilding the hospital was missed. He described the Povall Worthington report as 'lacking vision.' (KoHiN press release, 23 April 1997)

Geoff Clayton told me in an interview that building hospitals outside cities was 'old hat', and that Norwich was 10 years behind everyone else.

This model also relates to the non-implementation of policy. In this case KoHiN argued that Colney Hospital goes against PPG 6 and 13, although the response was that these guidelines had come later, and were not retrospective.

4.5 The Bureaucratic Politics Model
This is the second of Graham Allison's models, and mostly deals with the conflicts within institutions. (Greenaway et al. p32, 1992) Here, what is best for the Department of Health is not necessarily best for the Department of the Environment, and therefore not necessarily such a clear favourite for everyone. It is clearly within the interests of the NHS for this PFI flagship to be a success, although the costs to other departments may seem excessive.

This model ascribes a higher degree of influence to the civil service, and suggests that officers propose or oppose policies according to their own bureaucracy's interests or their own personal career prospects. This was shown by the conflict between Norwich City Council who were losing a hospital, and SNDC who were gaining one. There was some controversy about the motives of the SNDC Chief Planning Officer Michael Haslam, who personally pushed hard for the Colney Hospital.

5 Power

The issue of democracy is one of many that KoHiN campaigned about but were considered irrelevant to the supporters of the hospital who held the power. E.E. Schattschneider suggests that the scope of the conflict can affect the outcome. (As cited by Goodchild, 1998) Widening the scope of the debate by increasing the number of the issues considered, was a way in which KoHiN increased their power. The hospital may have been the best option on the narrow grounds of patient care. However KoHiN wanted to examine the undemocratic nature of the decision, the effect on the city centre, the problems of access and encouraging car dependence, and the building on a greenfield site. Trying to block the widening of the debate involves the second dimension of power, which is discussed below.

The pluralistic power of the large amount of people against the closure of the hospital eventually came to nothing, although a substantial degree of pressure against the hospital was sustained for some time. Letters to the local newspapers and MPs was one outlet for this. However, the second and third dimensions of power held by the elites in favour of the Colney Hospital, overcame any influence 30 000 signatures may have had.

5.2 The Second Dimension of Power
Although it can be easy for some to dismiss this dimension of power as 'conspiratorial,' it is widely believe in this case that the public were denied access to information which kept the issue from being openly discussed. The NHS have refuted this allegation, saying, "The allegation of secretive negotiations by the Trust is one of perception rather than reality." (Oxford and Anglia NHS Executive, 1997) As discussed in 3.2 however, the feeling that the public consultation was unsatisfactory in its communication with the public seemed to be justified.

The widespread perception since the 1988 inquiry, that 'Norwich 2' would be a second hospital for the area helped keep the debate off the agenda for many years, which is classic second dimensional power. Private Eye included a piece on the N&N closure which stated "Public debate about the impact of the city centre closure...has been tactically avoided". (27 June 1997) As the issue of the closure of the N&N had been so low key at the 1988 planning inquiry that some people had missed it, there was never a proper opportunity for the informed public to challenge it.

Another clear case of second dimensional power was the excuse of 'commercial sensitivity' which prevented there being much news for the media to report between 1992 and 1995. The Trust will still not disclose the rental costs that will be paid to Octagon Healthcare, although in January 1998 it said these details would be released in 8-10 weeks. (Carlo, pers comm. 1998)

KoHiN also have been denied access to information such as the Povall Worthington report, which has prevented an informed, open discussion of it. It has been criticised for trying to raise other issues, which have been kept off the agenda by the hospital supporters, who were more likely to win on the narrower grounds of patient healthcare. There was no legally binding need for a socio-economic or environmental impact assessment, and as the statutory requirements for the public consultation were met, there was no reason to concede that these points should be discussed further. Rob Smith seemed to find the criticisms of the democratic process an affront to his idea of how our country works. He said,
"Rather than tackling the issues, they hammered on about the inequalities of the process. They were attacking democratic decisions, which I found very difficult...We have a democratic process in this country that we should go through. We have publicly accountable bodies that we elect to do certain tasks." (my emphasis)

Another manifestation of second dimensional power is when a course of action is agreed upon, but is not carried out at a later point when campaigners have less leverage. Potential voters put pressure on Charles Clark and Ian Gibson, the two Norwich MPs, to promise to hold a review of the hospital when they were elected. Once in office, they changed their minds.

5.3 The Third Dimension of Power
Norwich City Council did not oppose Colney in 1992, partly because they had the impression that there was 'no feasible alternative' (Carlo, pers comm. 1998) and partly because they did not realise the full extent to which the project was against their interests. Local businesses, were slow to support the KoHiN campaign, although the closure of the hospital was very much against their interests. When Michael Innes approached Jonathan Sissons, Head of the Chamber of Commerce, he said he had not considered the subject. (Carlo, pers comm. 1998)

The claim of 'no feasible alternative' was effectively used on several occasions. First in the presentation of the 1992 public consultation document which showed Colney as the best choice by quite a margin. Later PFI was "the only way for Government to fund hospitals in the current economic circumstances." (Clarke, 18 June 1997) It seems strange that these 'current economic circumstances' are so much worse than in the post-war period. It is also third dimensional power that prevents us from demanding that taxes are raised, or the defence budget cut, so that better healthcare can be provided with public money.

6 Sustainable Development

Public welfare does not solely depend on the quality of health care, but requires trade offs in many conflicting areas. Some members of the public considered other issues, relating to sustainable development, to be more important than 'an increased longevity'. The traditional environmental concerns about out-of-town developments apply here, namely the destruction of a greenfield site, and the potential increase in car usage. The other two branches of sustainable development - social justice and the economy - are also affected here, and were picked up upon in the campaign. Letters to the EDP and the Eastern Evening News showed a considerable concern for the elderly and those without cars, especially as these sectors of society need proportionally more health care. The negative impact on the local economy in Norwich was of particular concern to the architect Michael Innes, whose interest in this area had previously lead him to design the Castle Mall shopping centre in the city centre.

The Health Trust could claim that a rational decision was made, with adequate knowledge of all the options, and the closure of the N&N would lead to the best available health care for the local population in the long term. However, many people may not have seen this as the overriding priority. Only a more open and extensive consultation process could have revealed the trade offs the local population may have wanted to increase their welfare for now and the future.

7 Conclusion

As the two sides offer such conflicting views about which site is preferable with regard to access, it difficult to discern where the truth lies. Clearly this is the main issue for many people. Public transport and parking were the most common subjects brought up in letters to the EDP and the EEN. The inadequate parking at the N&N seems to be a main driving force behind the move, which definitely raises equity questions for the third of Norfolk without a car. According to Geoff Clayton, the priority given to parking is as if they intend to build a car park, (the largest in the county) and put a hospital next to it!

Although the Colney Hospital will have some definite advantages over the N&N, the groundswell of local opinion against it suggests that there were some quite powerful forces ensuring that it went ahead. Starting with the consultants that wanted a prestigious hospital with links to the UEA, and ending with the various groups that had an interest in this PFI flagship being a success, a series of powerful elites ensured that their opinions were heard. The power of the pluralism of the local people might have had some chance if it had had more support from the Department of the Environment, or the new Labour Government, but because it did not manage to secure this, it ultimately failed.

Rachel Boyd
UEA ENV 2
May 1998

"It is the people's national health service and we should never forget that."